Healthcare Provider Details

I. General information

NPI: 1457515322
Provider Name (Legal Business Name): EMAD T. FARAGALLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 MEADOWLANDS PKWY
SECAUCUS NJ
07094-2977
US

IV. Provider business mailing address

282 ILYSSA WAY
STATEN ISLAND NY
10312-1382
US

V. Phone/Fax

Practice location:
  • Phone: 201-392-3100
  • Fax:
Mailing address:
  • Phone: 718-605-6651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA08397800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number248387
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: