Provider Demographics
NPI:1952430498
Name:FAUST, PHYLLIS LYNN (MD, PHD)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:LYNN
Last Name:FAUST
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 W 168TH ST
Mailing Address - Street 2:PH 1564W
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3720
Mailing Address - Country:US
Mailing Address - Phone:212-305-7399
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:PH 1564W
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:212-305-7399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY187131207ZN0500X
NY187131-1207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I31091Medicare UPIN
NY823671Medicare ID - Type Unspecified