Basic Information
| Provider Information | |||||||||
| NPI: | 1700932175 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAHNRICH | ||||||||
| FirstName: | BRIAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 484 TEMPLE HILL RD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | NEW WINDSOR | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125535557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455653700 | ||||||||
| FaxNumber: | 8455653395 | ||||||||
| Practice Location | |||||||||
| Address1: | 2475 SAINT RAYMONDS AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104613124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188241514 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207P00000X | 180678 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01190110 | 05 | NY | MEDICAID |