Provider Demographics
NPI:1336235639
Name:DR. FAZELI & DR. BROUMAND LLC
Entity Type:Organization
Organization Name:DR. FAZELI & DR. BROUMAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FAZELI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-663-0100
Mailing Address - Street 1:4110 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-6613
Mailing Address - Country:US
Mailing Address - Phone:315-663-0100
Mailing Address - Fax:585-663-0052
Practice Address - Street 1:4110 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6613
Practice Address - Country:US
Practice Address - Phone:315-663-0100
Practice Address - Fax:315-663-0052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY17719AMedicare ID - Type Unspecified