Healthcare Provider Details

I. General information

NPI: 1417935628
Provider Name (Legal Business Name): FREDRIC BOMBACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 01/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 FIELDSTONE DR
HARTSDALE NY
10530-1564
US

IV. Provider business mailing address

99 FIELDSTONE DR
HARTSDALE NY
10530-1564
US

V. Phone/Fax

Practice location:
  • Phone: 914-428-2120
  • Fax:
Mailing address:
  • Phone: 914-428-2120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number106826
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number106826
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: