Basic Information
| Provider Information | |||||||||
| NPI: | 1053358689 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FALLICK | ||||||||
| FirstName: | FREDERICK | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41 CONCORD RD | ||||||||
| Address2: | |||||||||
| City: | ARDSLEY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105021111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146936133 | ||||||||
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| Practice Location | |||||||||
| Address1: | SCARSDALE MEDICAL GROUP | ||||||||
| Address2: | 600 MAMARONECK AVENUE | ||||||||
| City: | HARRISON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9147238100 | ||||||||
| FaxNumber: | 9142191928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 207RG0100X | 180848 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 01744238 | 05 | NY | MEDICAID |