Basic Information
| Provider Information | |||||||||
| NPI: | 1093883910 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FACCIUTO | ||||||||
| FirstName: | MARCELO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 GUSTAVE L LEVY PL | ||||||||
| Address2: | BOX 1104 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126598096 | ||||||||
| FaxNumber: | 2122412064 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 E 98TH ST | ||||||||
| Address2: | 12TH FL | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126598096 | ||||||||
| FaxNumber: | 2122412064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 05/18/2012 | ||||||||
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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 | 204F00000X | 226190 | NY | Y | Allopathic & Osteopathic Physicians | Transplant Surgery | 208600000X | 226190 | NY | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 02473247 | 05 | NY | MEDICAID |