MEDICARE: MR. JOHN FITZGERALD RN

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	163WP0808X	Psychiatric/Mental Health Registered Nurse	500751	NY

General Provider Information

NPI Number	:	1891062436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN FITZGERALD RN

Provider Business Mailing Address
First Line	:	1 FARMINGDALE RD
Second Line	:
City	:	WEST BABYLON
State	:	NY
Zip	:	11704-6207
Country	:	US
Telephone Number	:	631-669-5355
Fax Number	:	631-669-1471

Provider Business Practice Location Address
First Line	:	1 FARMINGDALE RD
Second Line	:
City	:	WEST BABYLON
State	:	NY
Zip	:	11704-6207
Country	:	US
Telephone Number	:	631-669-5355
Fax Number	:	631-669-1471

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

Provider Enumeration Date	:	11/28/2011
Last Update Date	:	11/28/2011

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