Healthcare Provider Details

I. General information

NPI: 1508314774
Provider Name (Legal Business Name): FRESH MEADOWS MEDICAL SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2016
Last Update Date: 10/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18904 UNION TPKE
FRESH MEADOWS NY
11366-1862
US

IV. Provider business mailing address

PO BOX 270
MASSAPEQUA PARK NY
11762-0270
US

V. Phone/Fax

Practice location:
  • Phone: 718-217-1414
  • Fax:
Mailing address:
  • Phone: 631-264-2035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: ALAN ANTONELLI
Title or Position: OWNER
Credential: MD
Phone: 718-217-1414