Basic Information
Provider Information | |||||||||
NPI: | 1083712772 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FATH | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | B | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 550 MAMARONECK AVE | ||||||||
Address2: | SUITE 302 | ||||||||
City: | HARRISON | ||||||||
State: | NY | ||||||||
PostalCode: | 105281634 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9147238100 | ||||||||
FaxNumber: | 9142191928 | ||||||||
Practice Location | |||||||||
Address1: | 259 HEATHCOTE RD | ||||||||
Address2: |   | ||||||||
City: | SCARSDALE | ||||||||
State: | NY | ||||||||
PostalCode: | 105834523 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9147238100 | ||||||||
FaxNumber: | 9142191928 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2006 | ||||||||
LastUpdateDate: | 02/10/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 139040 | NY | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 11092405 | 01 | NY | MEDICARE RAILROAD | OTHER | 487207 | 01 | NY | UNITED HEALTH CARE | OTHER | 137403 | 01 | NY | ONE HEALTH PLAN | OTHER | WP484 | 01 | NY | OXFORD HEALTH PLANS | OTHER | 00767097 | 05 | NY |   | MEDICAID |