1720346406 NPI number — MR. MICHAEL TIMOTHY BUCKLEY CASAC

Table of content: MR. MICHAEL TIMOTHY BUCKLEY CASAC (NPI 1720346406)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720346406 NPI number — MR. MICHAEL TIMOTHY BUCKLEY CASAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUCKLEY
Provider First Name:
MICHAEL
Provider Middle Name:
TIMOTHY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CASAC
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:
1720346406
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
449 39TH ST
Provider Second Line Business Mailing Address:
4TH FLOOR
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11232-2909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-871-7433
Provider Business Mailing Address Fax Number:
718-871-7419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
449 39TH ST
Provider Second Line Business Practice Location Address:
4TH FLOOR
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11232-2909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-871-7433
Provider Business Practice Location Address Fax Number:
718-871-7419
Provider Enumeration Date:
05/01/2012

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: 101YA0400X , with the licence number:  CASAC 17580 , 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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