1053501700 NPI number — RONALD G. BASALYGA, M.D. PC

Table of content: (NPI 1053501700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053501700 NPI number — RONALD G. BASALYGA, M.D. PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RONALD G. BASALYGA, M.D. PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053501700
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4711 PINECREST TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDEN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14057-9757
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-649-5188
Provider Business Mailing Address Fax Number:
716-649-5188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4711 PINECREST TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDEN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14057-9757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-649-5188
Provider Business Practice Location Address Fax Number:
716-649-5188
Provider Enumeration Date:
07/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BASALYGA
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
716-649-5188

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  095710 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1225240609 . This is a "MD NPI #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2308442 . This is a "HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00591846 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: DD3550 . This is a "MD-MEDICARE ID #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00010011502 . This is a "HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: AA1447 . This is a "PC MEDICARE ID #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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