MEDICARE: FREDERIC A MENDELSOHN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	112676	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336247691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FREDERIC A MENDELSOHN MD

Provider Business Mailing Address
First Line	:	PO BOX 491
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-0491
Country	:	US
Telephone Number	:	631-737-0055
Fax Number	:	631-737-0076

Provider Business Practice Location Address
First Line	:	650 HAWKINS AVE
Second Line	:	SUITE 7
City	:	RONKONKOMA
State	:	NY
Zip	:	11779-2366
Country	:	US
Telephone Number	:	631-737-0055
Fax Number	:	631-737-0076

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/21/2010

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