Provider Demographics
NPI:1831266493
Name:MID-HUDSON OPHTHALMOLOGICAL RETINA CONSULTANTS, PLLC
Entity type:Organization
Organization Name:MID-HUDSON OPHTHALMOLOGICAL RETINA CONSULTANTS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOCICERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-692-0834
Mailing Address - Street 1:450 GIDNEY AVE
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-3116
Mailing Address - Country:US
Mailing Address - Phone:845-562-1100
Mailing Address - Fax:845-562-1162
Practice Address - Street 1:450 GIDNEY AVE
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-3116
Practice Address - Country:US
Practice Address - Phone:845-562-1100
Practice Address - Fax:845-562-1162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149190207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY192875-2OtherLICENSE
NY149190-1OtherLICENSE
NY00718525Medicaid
NY192875-2OtherLICENSE