MEDICARE: DR. ERIC A. FERTUCK PH.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	103TC0700X	Clinical Psychologist	13946	NY

General Provider Information

NPI Number	:	1821303843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC A. FERTUCK PH.D.

Provider Business Mailing Address
First Line	:	286 MADISON AVE
Second Line	:	NEW YORK
City	:	NEW YORK
State	:	NY
Zip	:	10017-6345
Country	:	US
Telephone Number	:	212-213-5088
Fax Number	:

Provider Business Practice Location Address
First Line	:	286 MADISON AVE
Second Line	:	NEW YORK
City	:	NEW YORK
State	:	NY
Zip	:	10017-6345
Country	:	US
Telephone Number	:	212-213-5088
Fax Number	:

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

Provider Enumeration Date	:	08/13/2010
Last Update Date	:	08/13/2010

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