Basic Information
| Provider Information | |||||||||
| NPI: | 1780886366 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BARALL | ||||||||
| FirstName: | BERTRAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14757 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113541436 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 WRIGHT AVENUE | ||||||||
| Address2: | |||||||||
| City: | MARCY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157368271 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2084P0800X | 078902 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 078902 | 05 | NY | MEDICAID |