Basic Information
| Provider Information | |||||||||
| NPI: | 1417007261 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOMBERSTEIN | ||||||||
| FirstName: | BARRY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 EAST 233RD STREET | ||||||||
| Address2: | MONTEFIORE MEDICAL CENTER - NORTH DIVISION | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104662604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189209168 | ||||||||
| FaxNumber: | 7189209036 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 E 233RD ST | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104662604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189209168 | ||||||||
| FaxNumber: | 7189209036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 11/02/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | 131884 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 00995744 | 05 | NY | MEDICAID |