MEDICARE: FALLON ANDREA MATTIS M.D.

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	207Q00000X	Family Medicine Physician	R7061	TX
2	207Q00000X	Family Medicine Physician	63188	MN
3	207Q00000X	Family Medicine Physician	036144488	IL
4	207Q00000X	Family Medicine Physician	2017034134	MO
5	207Q00000X	Family Medicine Physician	10501937-1205	UT
6	207Q00000X	Family Medicine Physician	273617-1	NY
7	207Q00000X	Family Medicine Physician	25MA10713600	NJ
8	207Q00000X	Family Medicine Physician	0101257845	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1558686345	OTHER	NY	FAMILY MEDICINE

General Provider Information

NPI Number	:	1558686345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FALLON ANDREA MATTIS M.D.

Provider Business Mailing Address
First Line	:	1103 N MAIN ST
Second Line	:
City	:	SOUTH BOSTON
State	:	VA
Zip	:	24592-2511
Country	:	US
Telephone Number	:	646-835-9001
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 AUBREYS LOOP
Second Line	:	SENTARA HALIFAX FAMILY MEDICINE
City	:	SOUTH BOSTON
State	:	VA
Zip	:	24592-5054
Country	:	US
Telephone Number	:	646-835-9001
Fax Number	:	646-835-9001

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

Provider Enumeration Date	:	04/05/2010
Last Update Date	:	10/30/2019

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