Basic Information
| Provider Information | |||||||||
| NPI: | 1083614226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERSANI | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2003 | ||||||||
| Address2: | |||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130574503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154463904 | ||||||||
| FaxNumber: | 3154452936 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 VICKERY RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | NORTH SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132124540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154223937 | ||||||||
| FaxNumber: | 3154224432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 07/05/2012 | ||||||||
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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 | 207W00000X | 170204 | NY | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 820000028 | 01 | RRMCR | OTHER | 820000028 | 01 | RAIL ROAD MEDICARE | OTHER |