1679653448 NPI number — J ANDREW FANTL GYNECOLOGY PC

Table of content: (NPI 1679653448)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679653448 NPI number — J ANDREW FANTL GYNECOLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J ANDREW FANTL GYNECOLOGY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679653448
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 MIDDLE COUNTRY RD
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
SMITHTOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11787
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-979-2842
Provider Business Mailing Address Fax Number:
631-979-2845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 MIDDLE COUNTRY RD
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
SMITHTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11787
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-979-2842
Provider Business Practice Location Address Fax Number:
631-979-2845
Provider Enumeration Date:
10/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FANTL
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
DOCTOR PRESIDENT
Authorized Official Telephone Number:
631-979-2842

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X , with the licence number:  1988811 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9658042 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5817720 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 665C41 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 198881 . This is a "HIP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 53073 . This is a "VYTRA" identifier . This identifiers is of the category "OTHER".
  • Identifier: P1935301 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: P62326327 . This is a "MULTIPLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: AA50860 . This is a "MDNY" identifier . This identifiers is of the category "OTHER".




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