Provider Demographics
NPI:1730228370
Name:RICHARD A. FAZIO MD, P.C.
Entity type:Organization
Organization Name:RICHARD A. FAZIO MD, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:FAZIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-748-2110
Mailing Address - Street 1:1102 BAY RIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-2338
Mailing Address - Country:US
Mailing Address - Phone:718-748-2110
Mailing Address - Fax:718-748-1666
Practice Address - Street 1:1102 BAY RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228-2338
Practice Address - Country:US
Practice Address - Phone:718-748-2110
Practice Address - Fax:718-748-1666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEH951Medicare PIN