Provider Demographics
NPI:1215361183
Name:PIDICH, ALYSON RAKEL (MD)
Entity Type:Individual
Prefix:
First Name:ALYSON
Middle Name:RAKEL
Last Name:PIDICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 BEDFORD ST APT 2C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-3787
Mailing Address - Country:US
Mailing Address - Phone:833-303-4325
Mailing Address - Fax:
Practice Address - Street 1:93 BEDFORD ST APT 2C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014-3787
Practice Address - Country:US
Practice Address - Phone:833-303-4325
Practice Address - Fax:646-871-6885
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-28
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT205349207R00000X
NY280171207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400133747Medicare PIN