Basic Information
Provider Information | |||||||||
NPI: | 1346372828 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BISCONTI | ||||||||
FirstName: | NICHOLAS | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 80690 | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | OH | ||||||||
PostalCode: | 447080690 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3303637444 | ||||||||
FaxNumber: | 3303637770 | ||||||||
Practice Location | |||||||||
Address1: | 2600 SEVENTH ST SW | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | OH | ||||||||
PostalCode: | 447101709 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3304534300 | ||||||||
FaxNumber: | 3304533617 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/11/2007 | ||||||||
LastUpdateDate: | 01/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 35054433 | OH | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 0787402 | 05 | OH |   | MEDICAID |