MEDICARE: MRS. JUNE H FONTANES PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	12267	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7272494	OTHER	NY	AETNA
2	99540	OTHER	NY	VYTRA

General Provider Information

NPI Number	:	1275514374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JUNE H FONTANES PT

Provider Business Mailing Address
First Line	:	2 SELDEN DR
Second Line	:
City	:	E NORTHPORT
State	:	NY
Zip	:	11731-1342
Country	:	US
Telephone Number	:	631-261-9150
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 BROADWAY
Second Line	:
City	:	MASSAPEQUA
State	:	NY
Zip	:	11758-2324
Country	:	US
Telephone Number	:	516-797-7003
Fax Number	:	516-797-7336

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	07/08/2007

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