1649492554 NPI number — MICHAEL HERCEG DO

Table of content: MICHAEL HERCEG DO (NPI 1649492554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649492554 NPI number — MICHAEL HERCEG DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERCEG
Provider First Name:
MICHAEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1649492554
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22 PINE MEADOW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VESTAL
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13850-3042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-217-5372
Provider Business Mailing Address Fax Number:
607-723-1989

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33 MITCHELL AVE
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
BINGHAMTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13903-1674
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-723-7586
Provider Business Practice Location Address Fax Number:
607-723-1989
Provider Enumeration Date:
05/02/2007

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: 207W00000X , with the licence number:  OS014046 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 247466-1 , 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: 02061489 . This is a "MEDICAID GROUP ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: AA0477 . This is a "MEDICARE GROUP PROVIDER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02992038 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".