Provider Demographics
NPI:1871676841
Name:FEALEY, THOMAS EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:EDWARD
Last Name:FEALEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-2833
Mailing Address - Country:US
Mailing Address - Phone:718-448-4747
Mailing Address - Fax:
Practice Address - Street 1:723 BROADWAY
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-2833
Practice Address - Country:US
Practice Address - Phone:718-448-4747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY147651174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY74A811Medicare ID - Type Unspecified
NYB19157Medicare UPIN