Provider Demographics
NPI:1548853708
Name:FINE, GREGORY FITZGERALD
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:FITZGERALD
Last Name:FINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1934 CARROLL AVE
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-2625
Mailing Address - Country:US
Mailing Address - Phone:516-379-0810
Mailing Address - Fax:
Practice Address - Street 1:188 MERRICK RD
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-4532
Practice Address - Country:US
Practice Address - Phone:516-379-0810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner