Basic Information
| Provider Information | |||||||||
| NPI: | 1740254937 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BISACCO | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | FRANCIS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WATER ST | ||||||||
| Address2: | 12TH FLOOR CREDENTIALING | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100410004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466802888 | ||||||||
| FaxNumber: | 5165425556 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 BAY SHORE RD | ||||||||
| Address2: | |||||||||
| City: | NORTH BABYLON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117032823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315862700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 02/02/2017 | ||||||||
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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 | 208000000X | 1625261 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00944821 | 05 | NY | MEDICAID |