1700890837 NPI number — ALYSE R BELLOMO MD

Table of content: ALYSE R BELLOMO MD (NPI 1700890837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700890837 NPI number — ALYSE R BELLOMO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BELLOMO
Provider First Name:
ALYSE
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1700890837
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
466 OLD HOOK ROAD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
EMERSON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07630-1368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
466 OLD HOOK ROAD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
EMERSON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07630-1368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-272-0234
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2006

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: 207RG0100X , with the licence number:  183197-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 25MA08394400 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5269090 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 107014 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000405355001 . This is a "BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 39J23 . This is a "EMPIRE BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 127303 . This is a "WELLCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 040426006461 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 100008772 . This is a "RR/MCR" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 27303 . This is a "GHI/HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1638733 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2505278 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10002444 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1415851130011 . This is a "CIGNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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