Provider Demographics
NPI:1801251814
Name:FRIENDLY MEDICAL GROUP PC
Entity type:Organization
Organization Name:FRIENDLY MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:TEDESCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-689-6226
Mailing Address - Street 1:207 HALLOCK ROAD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790
Mailing Address - Country:US
Mailing Address - Phone:631-689-6226
Mailing Address - Fax:631-675-0736
Practice Address - Street 1:207 HALLOCK ROAD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790
Practice Address - Country:US
Practice Address - Phone:631-689-6226
Practice Address - Fax:631-675-0736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY462504208000000X
NY154768208000000X
NY60275504208000000X
208000000X
NY248234208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty