MEDICARE: JOHN FIORDALISI MD PLLC

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	207L00000X	Anesthesiology Physician	169238	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	299T01	OTHER		BC/BS

General Provider Information

NPI Number	:	1952571572
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN FIORDALISI MD PLLC

Provider Business Mailing Address
First Line	:	35 HAMPTON BAYS DR
Second Line	:
City	:	HAMPTON BAYS
State	:	NY
Zip	:	11946-3007
Country	:	US
Telephone Number	:	646-406-5404
Fax Number	:	718-320-7225

Provider Business Practice Location Address
First Line	:	166 E 88TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10128-2255
Country	:	US
Telephone Number	:	646-406-5404
Fax Number	:

Authorized Official
Title or Position	:	ANESTHESIOLOGY
Name	:	DR. JOHN FIORDALISI
Credential	:	MD
Telephone Number	:	646-406-5404

Provider Enumeration Date	:	03/11/2008
Last Update Date	:	04/01/2008

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