Basic Information
| Provider Information | |||||||||
| NPI: | 1083612584 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAO | ||||||||
| FirstName: | MYLAR | ||||||||
| MiddleName: | B. R. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | RAO | ||||||||
| OtherFirstName: | B. R. | ||||||||
| OtherMiddleName: | MYLAR | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 68 S SERVICE RD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117472354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169453000 | ||||||||
| FaxNumber: | 5169453131 | ||||||||
| Practice Location | |||||||||
| Address1: | 45 READE PL | ||||||||
| Address2: | |||||||||
| City: | POUGHKEEPSIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 126013947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8454315629 | ||||||||
| FaxNumber: | 5169453131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 08/18/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 104995 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00183019 | 05 | NY | MEDICAID |