Basic Information
| Provider Information | |||||||||
| NPI: | 1851395628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRIED | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 235 N BELLE MEAD RD | ||||||||
| Address2: | |||||||||
| City: | E SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117333456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317513000 | ||||||||
| FaxNumber: | 6317513366 | ||||||||
| Practice Location | |||||||||
| Address1: | 285 SILLS RD | ||||||||
| Address2: | BLDG 16 | ||||||||
| City: | EAST PATCHOGUE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117724808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317587575 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 12/19/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 128126 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 01337008 | 05 | NY | MEDICAID |