Provider Demographics
NPI:1558722546
Name:ST SEBASTIAN MEDICAL PC
Entity Type:Organization
Organization Name:ST SEBASTIAN MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ALEXSANDER
Authorized Official - Middle Name:V
Authorized Official - Last Name:BALDONADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-397-7563
Mailing Address - Street 1:20 W 190TH ST # W
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-4356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 W 190TH ST # W
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-4356
Practice Address - Country:US
Practice Address - Phone:999-999-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization