Provider Demographics
NPI:1609058858
Name:ROBERT M CONENELLO
Entity type:Organization
Organization Name:ROBERT M CONENELLO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CONENELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:845-365-3103
Mailing Address - Street 1:450 WESTERN HWY
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:NY
Mailing Address - Zip Code:10962-2187
Mailing Address - Country:US
Mailing Address - Phone:845-365-3103
Mailing Address - Fax:845-365-3253
Practice Address - Street 1:450 WESTERN HWY
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:NY
Practice Address - Zip Code:10962-2187
Practice Address - Country:US
Practice Address - Phone:845-365-3103
Practice Address - Fax:845-365-3253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004796-1213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4437880001Medicare NSC