MEDICARE: MOHAWK VALLEY PHYSICAL MEDICINE AND REHAB

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	208100000X	Physical Medicine & Rehabilitation Physician	197917	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	OPPMR 197917-8	OTHER	NY	WORKMANS COMP
3	1538364237	OTHER	NY	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1720051428
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOHAWK VALLEY PHYSICAL MEDICINE AND REHAB

Provider Business Mailing Address
First Line	:	4988 STATE HIGHWAY 30
Second Line	:
City	:	AMSTERDAM
State	:	NY
Zip	:	12010-7520
Country	:	US
Telephone Number	:	518-841-3481
Fax Number	:	518-841-3582

Provider Business Practice Location Address
First Line	:	4988 STATE HIGHWAY 30
Second Line	:	ST. MARY'S HOSPITAL MEMORIAL CAMPUS
City	:	AMSTERDAM
State	:	NY
Zip	:	12010-7520
Country	:	US
Telephone Number	:	518-841-3481
Fax Number	:	518-841-3481

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN LEWIS FEDULLO
Credential	:	D. O.
Telephone Number	:	518-841-3481

Provider Enumeration Date	:	02/12/2006
Last Update Date	:	03/07/2013

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Directions to “MOHAWK VALLEY PHYSICAL MEDICINE AND REHAB ” Practice Location

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