=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396876777
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HERBERT CAMPBELL RADER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 ADAMS STREET
-----------------------------------------------------
City | FLORAL PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11001-2810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-692-8595
-----------------------------------------------------
Fax | 718-692-8534
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 ADAMS STREET
-----------------------------------------------------
City | FLORAL PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11001-2810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-692-8595
-----------------------------------------------------
Fax | 718-692-8534
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 104477
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------