Provider Demographics
NPI:1649258344
Name:BIANCO, MICHAEL A (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:BIANCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 BOYLE ROAD
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784
Mailing Address - Country:US
Mailing Address - Phone:631-736-4064
Mailing Address - Fax:631-736-1332
Practice Address - Street 1:1000 MONTAUK HWY
Practice Address - Street 2:GOOD SAMARITAN HOSPITAL
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795
Practice Address - Country:US
Practice Address - Phone:631-736-4064
Practice Address - Fax:631-736-1332
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204408-1207L00000X
CT49224207L00000X
NY204408207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01781277Medicaid
NY60X611Medicare ID - Type Unspecified
G58074Medicare UPIN