=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780607192
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MILLIE R FELL MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 03/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2025 KINGS HWY
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11229-1463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-339-6868
-----------------------------------------------------
Fax | 718-627-7219
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2025 KINGS HWY
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11229-1463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-339-6868
-----------------------------------------------------
Fax | 718-627-7219
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 160237-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------