Provider Demographics
NPI:1407899388
Name:BIANCANIELLO, THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:BIANCANIELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 SOUTHERN BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-1091
Mailing Address - Country:US
Mailing Address - Phone:631-265-3300
Mailing Address - Fax:631-265-3303
Practice Address - Street 1:57 SOUTHERN BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-1091
Practice Address - Country:US
Practice Address - Phone:631-265-3300
Practice Address - Fax:631-265-3303
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1272672080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4313729OtherAETNA
NY00524474Medicaid
NY133908648OtherUNITEDHEALTHCARE EMPIRE PLAN NETWORK
NYB14099Medicare UPIN
NY133908648OtherUNITEDHEALTHCARE EMPIRE PLAN NETWORK