Provider Demographics
NPI:1871041269
Name:BISHOP, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BISHOP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MERLE PL
Mailing Address - Street 2:APT 6B
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3754
Mailing Address - Country:US
Mailing Address - Phone:917-596-2644
Mailing Address - Fax:
Practice Address - Street 1:1000 SOUTH AVE
Practice Address - Street 2:SUITE LL2
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3409
Practice Address - Country:US
Practice Address - Phone:718-477-0961
Practice Address - Fax:718-761-1643
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053339161174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist