Provider Demographics
NPI:1053430256
Name:TRI STATE EYE OPHTHALMOLOGY OF MIDDLETOWN PC
Entity type:Organization
Organization Name:TRI STATE EYE OPHTHALMOLOGY OF MIDDLETOWN PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SEVERIN
Authorized Official - Middle Name:BOHDAN
Authorized Official - Last Name:PALYDOWYCZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-296-9696
Mailing Address - Street 1:75 CRYSTAL RUN RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-7000
Mailing Address - Country:US
Mailing Address - Phone:845-703-2020
Mailing Address - Fax:845-703-2901
Practice Address - Street 1:75 CRYSTAL RUN RD
Practice Address - Street 2:SUITE 120
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-7000
Practice Address - Country:US
Practice Address - Phone:845-703-2020
Practice Address - Fax:845-703-2901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYMD049303L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
I04325Medicare UPIN
U81549Medicare UPIN
F52262Medicare UPIN