MEDICARE: MARK PANDOLFI LMSW

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	104100000X	Social Worker	040008-1	NY

General Provider Information

NPI Number	:	1497096598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK PANDOLFI LMSW

Provider Business Mailing Address
First Line	:	790 PARK AVENUE
Second Line	:
City	:	HUNTINGTON
State	:	NY
Zip	:	11790
Country	:	US
Telephone Number	:	631-427-3700
Fax Number	:

Provider Business Practice Location Address
First Line	:	220 MAIN ST
Second Line	:
City	:	CENTER MORICHES
State	:	NY
Zip	:	11934-3516
Country	:	US
Telephone Number	:	631-874-2700
Fax Number	:

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

Provider Enumeration Date	:	03/14/2013
Last Update Date	:	03/14/2013

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