Basic Information
| Provider Information | |||||||||
| NPI: | 1063417327 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CIPOLLA | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1486 DEER PARK AVE UNIT A | ||||||||
| Address2: | |||||||||
| City: | NORTH BABYLON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117031214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314223200 | ||||||||
| FaxNumber: | 6314226597 | ||||||||
| Practice Location | |||||||||
| Address1: | 1486 DEER PARK AVE UNIT A | ||||||||
| Address2: | |||||||||
| City: | NORTH BABYLON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117031214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314223200 | ||||||||
| FaxNumber: | 6314226597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 03/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 175335 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0435421 | 01 | NY | CIGNA | OTHER | 0976486000 | 01 | NY | AMERIHEALTH ID # | OTHER | CIM175335 | 01 | NY | NF/WC | OTHER | P62369454 | 01 | NY | MULTIPLAN | OTHER | 175335 | 01 | NY | LICENSE # | OTHER | 01572247 | 05 | NY | MEDICAID | 2505064 | 01 | NY | GHI | OTHER | 010175331NY01 | 01 | NY | ANTHEM HEALTH ID# | OTHER | 045244 | 01 | NY | AETNA/US HEALTHCARE | OTHER | 4331591 | 01 | NY | AETNA ID | OTHER | 110227279 | 01 | NY | RAILROAD MEDICARE | OTHER | 1143305 | 01 | NY | UNITED HEALTHCARE | OTHER | 3C3154 | 01 | NY | HEALTHNET | OTHER | 08G261 | 01 | NY | BLUE CROSS BLUE SHIELD ID | OTHER | 41397 | 01 | NY | VYTRA | OTHER | CP542 | 01 | NY | OXFORD | OTHER |