1326086216 NPI number — PRIVILAGE MASONI M.D.

Table of content: PRIVILAGE MASONI M.D. (NPI 1326086216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326086216 NPI number — PRIVILAGE MASONI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASONI
Provider First Name:
PRIVILAGE
Provider Middle Name:
Provider Name Prefix Text:
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:
1326086216
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40769
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STATEN ISLAND
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10304-0769
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-448-7543
Provider Business Mailing Address Fax Number:
718-448-0045

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1032 VICTORY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATEN ISLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10301-3626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-448-7543
Provider Business Practice Location Address Fax Number:
718-448-0045
Provider Enumeration Date:
06/03/2006

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: 207PE0004X , with the licence number:  18629 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: 246241 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 246241 , 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: 246241 . This is a "NEW YORK STATE LICENSE NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1110949 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01284873 . This is a "AMERIGROUP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 03079352 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 090702000026 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 9999999988 . This is a "AFFINITY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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