Provider Demographics
NPI:1558481796
Name:BIERSACK, KATHY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHY
Middle Name:LYNN
Last Name:BIERSACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:18 CHARLESTON DR
Mailing Address - Street 2:
Mailing Address - City:HALESITE
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2305
Mailing Address - Country:US
Mailing Address - Phone:631-549-7180
Mailing Address - Fax:
Practice Address - Street 1:7520 ASTORIA BLVD
Practice Address - Street 2:
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11370-1131
Practice Address - Country:US
Practice Address - Phone:718-888-6960
Practice Address - Fax:718-565-8387
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219257207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF23397Medicare UPIN