Provider Demographics
NPI:1295957884
Name:FIDEL, ROSALYN (PT)
Entity type:Individual
Prefix:
First Name:ROSALYN
Middle Name:
Last Name:FIDEL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 TERRY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-265-4485
Mailing Address - Fax:631-265-3620
Practice Address - Street 1:45 TERRY RD
Practice Address - Street 2:NORTH SHORE NEUROLOGICAL & REHAB SUITE A
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-265-4485
Practice Address - Fax:631-265-3620
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0231741225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist