1609834415 NPI number — BERTHOLLET M BAVIBIDILA MD

Table of content: BERTHOLLET M BAVIBIDILA MD (NPI 1609834415)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609834415 NPI number — BERTHOLLET M BAVIBIDILA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAVIBIDILA
Provider First Name:
BERTHOLLET
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1609834415
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 KINGS HWY S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14617-5504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-922-0553
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1425 PORTLAND AVE
Provider Second Line Business Practice Location Address:
WILSON BLDG
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-338-1400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/02/2006

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:  203530 , 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: 00027212601 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 11121577 . This is a "CAQH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 110242022 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P010203530 . This is a "BLUE CHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00355266 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101660BJ . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1245 . This is a "SIDNEY HILLMAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 051006000001 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0414023 . This is a "IHA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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