MEDICARE: DR. DONALD FAGELMAN 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	2085R0202X	Diagnostic Radiology Physician	142132	NY

General Provider Information

NPI Number	:	1669476446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DONALD FAGELMAN MD

Provider Business Mailing Address
First Line	:	301 EAST MAIN ST.
Second Line	:	NSLIJ- SOUTHSIDE HOSPITAL, DEPT. OF RADIOLOGY
City	:	BAY SHORE
State	:	NY
Zip	:	11706
Country	:	US
Telephone Number	:	631-968-3290
Fax Number	:	631-968-7486

Provider Business Practice Location Address
First Line	:	301 EAST MAIN ST.
Second Line	:	NSLIJ- SOUTHSIDE HOSPITAL, DEPT. OF RADIOLOGY
City	:	BAY SHORE
State	:	NY
Zip	:	11706
Country	:	US
Telephone Number	:	631-968-3290
Fax Number	:	631-968-7486

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

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	06/11/2015

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