Provider Demographics
NPI:1588737357
Name:SHEREDOS-FUNFGELD, CATHY L (PA)
Entity type:Individual
Prefix:MRS
First Name:CATHY
Middle Name:L
Last Name:SHEREDOS-FUNFGELD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 GARDNER AVE
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2463
Mailing Address - Country:US
Mailing Address - Phone:516-938-3622
Mailing Address - Fax:212-563-0605
Practice Address - Street 1:216 GARDNER AVE
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-2463
Practice Address - Country:US
Practice Address - Phone:516-938-3622
Practice Address - Fax:212-563-0605
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007659207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY554ALHMedicare ID - Type UnspecifiedGHI MEDICARE
NYP65633Medicare UPIN