1053430256 NPI number — TRI STATE EYE OPHTHALMOLOGY OF MIDDLETOWN PC

Table of content: (NPI 1053430256)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053430256 NPI number — TRI STATE EYE OPHTHALMOLOGY OF MIDDLETOWN PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI STATE EYE OPHTHALMOLOGY OF MIDDLETOWN PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1053430256
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 CRYSTAL RUN RD
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10941-7000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-703-2020
Provider Business Mailing Address Fax Number:
845-703-2901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 CRYSTAL RUN RD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10941-7000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-703-2020
Provider Business Practice Location Address Fax Number:
845-703-2901
Provider Enumeration Date:
03/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PALYDOWYCZ
Authorized Official First Name:
SEVERIN
Authorized Official Middle Name:
BOHDAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
570-296-9696

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MD049303L , 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)





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