Provider Demographics
NPI:1275574550
Name:PERSICO, MICHAEL G (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:G
Last Name:PERSICO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:441 9TH AVENUE
Mailing Address - Street 2:ACPNY CREDENTIALING OFFICE - 3RD FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001
Mailing Address - Country:US
Mailing Address - Phone:646-680-2894
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:260 W SUNRISE HWY
Practice Address - Street 2:SUITE 200
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-1011
Practice Address - Country:US
Practice Address - Phone:516-825-3600
Practice Address - Fax:516-823-2051
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2016-03-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY140320208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY46D393K511OtherMEDICARE ID
NY00905913Medicaid
NYC10127Medicare UPIN