1902884463 NPI number — PHILLIPH BIALECKI M.D.

Table of content: PHILLIPH BIALECKI M.D. (NPI 1902884463)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902884463 NPI number — PHILLIPH BIALECKI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BIALECKI
Provider First Name:
PHILLIPH
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:
1902884463
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
640 S. STATE ST
Provider Second Line Business Mailing Address:
MAIL CODE 3055
Provider Business Mailing Address City Name:
DOVER
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19901-3530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-744-6156
Provider Business Mailing Address Fax Number:
302-735-3845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
640 S STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOVER
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19901-3530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-744-6156
Provider Business Practice Location Address Fax Number:
302-735-3845
Provider Enumeration Date:
01/05/2006

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: 207P00000X , with the licence number:  C1-0027192 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 115112300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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