Basic Information
| Provider Information | |||||||||
| NPI: | 1043327620 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FANUCCHI | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 BRADHURST AVENUE | ||||||||
| Address2: | SUITE 3100N | ||||||||
| City: | HAWTHORNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105236007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149099018 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 19 BRADHURST AVE STE 2300N | ||||||||
| Address2: | |||||||||
| City: | HAWTHORNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105322140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149099018 | ||||||||
| FaxNumber: | 9144932416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 02/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | 139415 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 02913308 | 05 | NY | MEDICAID |