Provider Demographics
NPI:1134333081
Name:BASSIG, ANDREVITCH (RPT)
Entity type:Individual
Prefix:
First Name:ANDREVITCH
Middle Name:
Last Name:BASSIG
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 DOLSON AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-6461
Mailing Address - Country:US
Mailing Address - Phone:845-342-0746
Mailing Address - Fax:845-342-1397
Practice Address - Street 1:45 DOLSON AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-6461
Practice Address - Country:US
Practice Address - Phone:845-342-0746
Practice Address - Fax:845-342-1397
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022509225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10766681OtherCAQH
NYQL5651OtherBLUE CROSS BLUE SHIELD
NYLICENSEOther022509