1235166414 NPI number — DR. THOMAS LANG MAHONEY M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235166414 NPI number — DR. THOMAS LANG MAHONEY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAHONEY
Provider First Name:
THOMAS
Provider Middle Name:
LANG
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1235166414
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39 ROCK CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PITTSFORD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14534-2841
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-586-5656
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3875 E HENRIETTA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENRIETTA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14467-9147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-334-4200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2006

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: 207R00000X , with the licence number:  142554 , 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: 0977 . This is a "BCBS NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 142554 . This is a "LISCENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 010142554 . This is a "BLUE CHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 187A . This is a "PREFERRED CARE ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00762203 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: CIM 231398 . This is a "WORKERS COMP NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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