MEDICARE: KENNETH H PETERSEL MD PC

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	207R00000X	Internal Medicine Physician	137623	NY

General Provider Information

NPI Number	:	1750544771
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENNETH H PETERSEL MD PC

Provider Business Mailing Address
First Line	:	1617 FRONT ST
Second Line	:
City	:	EAST MEADOW
State	:	NY
Zip	:	11554-2345
Country	:	US
Telephone Number	:	516-794-1330
Fax Number	:

Provider Business Practice Location Address
First Line	:	1617 FRONT ST
Second Line	:
City	:	EAST MEADOW
State	:	NY
Zip	:	11554-2345
Country	:	US
Telephone Number	:	516-794-1330
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	LOIS PETERSEL
Credential	:
Telephone Number	:	516-794-1330

Provider Enumeration Date	:	07/09/2008
Last Update Date	:	07/09/2008

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