Provider Demographics
NPI:1053309484
Name:BLEGEN, MICHELLE PALIANI
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:PALIANI
Last Name:BLEGEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4435 SENECA RD
Mailing Address - Street 2:
Mailing Address - City:TRUMANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14886-9201
Mailing Address - Country:US
Mailing Address - Phone:607-387-5707
Mailing Address - Fax:607-387-4354
Practice Address - Street 1:4435 SENECA RD
Practice Address - Street 2:
Practice Address - City:TRUMANSBURG
Practice Address - State:NY
Practice Address - Zip Code:14886-9201
Practice Address - Country:US
Practice Address - Phone:607-387-5707
Practice Address - Fax:607-387-4354
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219007207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02164116Medicaid
NY02164116Medicaid
NYRB3773Medicare PIN