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General NPI Number Information
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NPI Number | 1649291451
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Entity Type | Individual
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Provider Name | KENNETH IRWIN FISHBERGER MD
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Gender | Male
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Dates
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Enumeration Date | 07/21/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 200 BELLE TERRE ROAD SUITE #110
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City | PORT JEFFERSON
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State | NY
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Zip | 11777
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Country | US
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Telephone | 631-642-9801
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Fax | 631-642-9805
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Provider Business Mailing Address
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Address Line | 200 BELLE TERRE ROAD SUITE #110
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City | PORT JEFFERSON
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State | NY
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Zip | 11777
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Country | US
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Telephone | 631-642-9801
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Fax | 631-642-9805
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 129974
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License Number State | NY
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