Healthcare Provider Details

I. General information

NPI: 1265602833
Provider Name (Legal Business Name): FAIROUZ NOURI HASSELMARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: FAIROUZ NOURI AL-OTHMAN M.D.

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 READE PL
POUGHKEEPSIE NY
12601-3947
US

IV. Provider business mailing address

1351 ROUTE 55 SUITE 200
LAGRANGEVILLE NY
12540-5108
US

V. Phone/Fax

Practice location:
  • Phone: 845-454-8500
  • Fax:
Mailing address:
  • Phone: 845-475-9660
  • Fax: 845-475-9938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number249042
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number249042
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number249042
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: