1255316493 NPI number — BETH A REALI OD

Table of content: BETH A REALI OD (NPI 1255316493)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255316493 NPI number — BETH A REALI OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REALI
Provider First Name:
BETH
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REALI
Provider Other First Name:
BETH
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1255316493
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4170 PENNEMITE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIVONIA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14487-9625
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-346-3422
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3333 W HENRIETTA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14623-3543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-424-5970
Provider Business Practice Location Address Fax Number:
585-424-5973
Provider Enumeration Date:
12/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  T005235 , 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: 122289 . This is a "COLE MANAGED CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: NY5235 . This is a "EYE MED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 101990 . This is a "HMO PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01436039 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P010005235 . This is a "BLUE CHOICE HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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