Healthcare Provider Details

I. General information

NPI: 1124459722
Provider Name (Legal Business Name): SERGE FENELON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2013
Last Update Date: 12/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 E 24TH ST
BROOKLYN NY
11210-1129
US

IV. Provider business mailing address

527 E 24TH ST
BROOKLYN NY
11210-1129
US

V. Phone/Fax

Practice location:
  • Phone: 718-434-0825
  • Fax:
Mailing address:
  • Phone: 718-434-0825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number124667
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number124667
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: