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General NPI Number Information
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NPI Number | 1720051428
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Entity Type | Organization
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Legal Business Name | MOHAWK VALLEY PHYSICAL MEDICINE AND REHAB
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Dates
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Enumeration Date | 02/12/2006
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Last Update Date | 03/07/2013
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Provider Practice Location Address
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Address Line | 4988 STATE HIGHWAY 30 ST. MARY'S HOSPITAL MEMORIAL CAMPUS
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City | AMSTERDAM
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State | NY
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Zip | 12010-7520
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Country | US
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Telephone | 518-841-3481
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Fax | 518-841-3481
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Provider Business Mailing Address
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Address Line | 4988 STATE HIGHWAY 30
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City | AMSTERDAM
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State | NY
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Zip | 12010-7520
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Country | US
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Telephone | 518-841-3481
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Fax | 518-841-3582
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOHN LEWIS FEDULLO
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Credential | D. O.
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Telephone | 518-841-3481
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 197917
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License Number State | NY
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