Basic Information
| Provider Information | |||||||||
| NPI: | 1992801344 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FACELLE | ||||||||
| FirstName: | THOMAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 GRAND ST | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | WARWICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109901035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8459873906 | ||||||||
| FaxNumber: | 8459875979 | ||||||||
| Practice Location | |||||||||
| Address1: | 257 LAFAYETTE AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SUFFERN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109014830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453698800 | ||||||||
| FaxNumber: | 8453570086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 11/07/2013 | ||||||||
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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 | 208600000X | 145054 | NY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 089D611 | 01 | EMPIRE BLUE CROSS | OTHER | 08647 | 01 | GHI HMO | OTHER | 0D3802 | 01 | HEALTHNET NE | OTHER | 145054 | 01 | HIP OF NY | OTHER | 4096594 | 01 | AETNA TRADITIONAL | OTHER | RS363 | 01 | OXFORD | OTHER | 0002459 | 01 | GHI | OTHER | 01015883 | 05 | NY | MEDICAID | 0095911 | 01 | AETNA HMO | OTHER |