Basic Information
Provider Information | |||||||||
NPI: | 1083676712 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLIEDER | ||||||||
FirstName: | ANDREA | ||||||||
MiddleName: | S. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 222 STATION PLZ N | ||||||||
Address2: | SUITE 606 | ||||||||
City: | MINEOLA | ||||||||
State: | NY | ||||||||
PostalCode: | 115013808 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5166632468 | ||||||||
FaxNumber: | 5166638824 | ||||||||
Practice Location | |||||||||
Address1: | 222 STATION PLZ N | ||||||||
Address2: | SUITE 606 | ||||||||
City: | MINEOLA | ||||||||
State: | NY | ||||||||
PostalCode: | 115013808 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5166632468 | ||||||||
FaxNumber: | 5166638824 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | 203195 | NY | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
ID | Type | State | Issuer | Description | 02335275 | 05 | NY |   | MEDICAID |