Provider Demographics
NPI:1104832302
Name:FAY, COLLEEN M (MD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:FAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-7606
Mailing Address - Country:US
Mailing Address - Phone:718-518-5814
Mailing Address - Fax:718-579-2939
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7606
Practice Address - Country:US
Practice Address - Phone:718-518-5814
Practice Address - Fax:718-579-3929
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163795207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1188825Medicaid
NY1188825Medicaid
NY57F141Medicare ID - Type Unspecified