=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679653448
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J ANDREW FANTL GYNECOLOGY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2006
-----------------------------------------------------
Last Update Date | 05/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 222 MIDDLE COUNTRY RD SUITE 203
-----------------------------------------------------
City | SMITHTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-979-2842
-----------------------------------------------------
Fax | 631-979-2845
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 222 MIDDLE COUNTRY RD SUITE 203
-----------------------------------------------------
City | SMITHTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-979-2842
-----------------------------------------------------
Fax | 631-979-2845
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR PRESIDENT
-----------------------------------------------------
Name | DR. JOHN ANDREW FANTL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 631-979-2842
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number | 1988811
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------