Provider Demographics
NPI:1700890837
Name:BELLOMO, ALYSE R (MD)
Entity Type:Individual
Prefix:
First Name:ALYSE
Middle Name:R
Last Name:BELLOMO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:466 OLD HOOK ROAD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1368
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:466 OLD HOOK ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:EMERSON
Practice Address - State:NJ
Practice Address - Zip Code:07630-1368
Practice Address - Country:US
Practice Address - Phone:518-272-0234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183197-1207RG0100X
NJ25MA08394400207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5269090OtherAETNA
NY107014OtherMVP
NY000405355001OtherBLUE SHIELD
NY39J23OtherEMPIRE BC/BS
NY127303OtherWELLCARE
NY040426006461OtherFIDELIS
NY100008772OtherRR/MCR
NY27303OtherGHI/HMO
NY1638733Medicaid
NY2505278OtherGHI
NY10002444OtherCDPHP
NY1415851130011OtherCIGNA
NY5269090OtherAETNA
NY1638733Medicaid