Provider Demographics
NPI:1720051428
Name:MOHAWK VALLEY PHYSICAL MEDICINE AND REHAB
Entity Type:Organization
Organization Name:MOHAWK VALLEY PHYSICAL MEDICINE AND REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:FEDULLO
Authorized Official - Suffix:
Authorized Official - Credentials:D O
Authorized Official - Phone:518-841-3481
Mailing Address - Street 1:4988 STATE HIGHWAY 30
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-7520
Mailing Address - Country:US
Mailing Address - Phone:518-841-3481
Mailing Address - Fax:518-841-3582
Practice Address - Street 1:4988 STATE HIGHWAY 30
Practice Address - Street 2:ST. MARY'S HOSPITAL MEMORIAL CAMPUS
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-7520
Practice Address - Country:US
Practice Address - Phone:518-841-3481
Practice Address - Fax:518-841-3481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-12
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197917208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01762629Medicaid
NYOPPMR 197917-8OtherWORKMANS COMP
NY1538364237OtherINDIVIDUAL NPI
NYX61105Medicare UPIN
NY01762629Medicaid