Basic Information
| Provider Information | |||||||||
| NPI: | 1609191261 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RABIDEAU | ||||||||
| FirstName: | BRIDGET | ||||||||
| MiddleName: | JAYLENE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HERNE | ||||||||
| OtherFirstName: | BRIDGET | ||||||||
| OtherMiddleName: | JAYLENE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 155 FINNY BLVD | ||||||||
| Address2: | |||||||||
| City: | MALONE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184830109 | ||||||||
| FaxNumber: | 5184830115 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 FINNY BLVD | ||||||||
| Address2: | |||||||||
| City: | MALONE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184830109 | ||||||||
| FaxNumber: | 5184830115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2010 | ||||||||
| LastUpdateDate: | 04/07/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | 009005-1 | NY | Y | Eye and Vision Services Providers | Technician/Technologist | Optician |
ID Information
| ID | Type | State | Issuer | Description | 01995615 | 05 | NY | MEDICAID |