Basic Information
| Provider Information | |||||||||
| NPI: | 1073753216 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEDERIAN | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | RN, CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14890 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122124890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185255634 | ||||||||
| FaxNumber: | 5186494094 | ||||||||
| Practice Location | |||||||||
| Address1: | 63 SHAKER RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122041030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184713636 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2009 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 005459 | NY | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 163WD0400X | 273819 | NY | Y | Nursing Service Providers | Registered Nurse | Diabetes Educator |
ID Information
| ID | Type | State | Issuer | Description | 04073814 | 05 | NY | MEDICAID |