Healthcare Provider Details

I. General information

NPI: 1740586833
Provider Name (Legal Business Name): FULTON STREET MEDICAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2011
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 FULTON STREET
FARMINGDALE NY
11735
US

IV. Provider business mailing address

101 FULTON STREET
FARMINGDALE NY
11735
US

V. Phone/Fax

Practice location:
  • Phone: 151-575-5585
  • Fax:
Mailing address:
  • Phone: 151-575-5585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number133799
License Number StateNY

VIII. Authorized Official

Name: MR. JOSEPH ASHLEY
Title or Position: PRESIDENT
Credential: MD
Phone: 15157555855