Basic Information
| Provider Information | |||||||||
| NPI: | 1073519799 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FENNER | ||||||||
| FirstName: | SAMUEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5024 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100875024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006274470 | ||||||||
| FaxNumber: | 4129375710 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 GUSTAVE L LEVY PL | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9172250485 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2005 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 179593 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 01256844 | 05 | NY | MEDICAID |