Provider Demographics
NPI:1689856395
Name:MICHAEL TEDFORD MD LLC
Entity Type:Organization
Organization Name:MICHAEL TEDFORD MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:TEDFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-561-4466
Mailing Address - Street 1:254 ROUTE 17K STE 204
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-8300
Mailing Address - Country:US
Mailing Address - Phone:845-561-4466
Mailing Address - Fax:845-561-7190
Practice Address - Street 1:254 ROUTE 17K
Practice Address - Street 2:STE 204
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550
Practice Address - Country:US
Practice Address - Phone:845-561-4466
Practice Address - Fax:845-561-7190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203269207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01899169Medicaid
NYG83994Medicare UPIN
NYWXPWX1Medicare PIN