Basic Information
| Provider Information | |||||||||
| NPI: | 1003860354 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FALLON | ||||||||
| FirstName: | EDMUND | ||||||||
| MiddleName: | FRANCIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 304 | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128010304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189266992 | ||||||||
| FaxNumber: | 5189266983 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 NORTH RD | ||||||||
| Address2: | |||||||||
| City: | WILTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128311308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185817256 | ||||||||
| FaxNumber: | 5189261965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 06/03/2008 | ||||||||
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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 | 207RE0101X | 108707 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 00381177 | 05 | NY | MEDICAID | P00402828 | 01 | NY | RR MEDICARE | OTHER |