Provider Demographics
NPI:1780156711
Name:FAN MEDICINE CONSULTANT,PLLC
Entity type:Organization
Organization Name:FAN MEDICINE CONSULTANT,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:FIORENZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-986-5394
Mailing Address - Street 1:35 LAURIE CT
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-2900
Mailing Address - Country:US
Mailing Address - Phone:718-986-5394
Mailing Address - Fax:718-785-9664
Practice Address - Street 1:1200 SOUTH AVE STE 301
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3420
Practice Address - Country:US
Practice Address - Phone:718-986-5394
Practice Address - Fax:718-785-9564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty