Basic Information
| Provider Information | |||||||||
| NPI: | 1750332292 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIBIASE | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5645 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113555045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186701501 | ||||||||
| FaxNumber: | 7184459846 | ||||||||
| Practice Location | |||||||||
| Address1: | 5645 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113555045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186701501 | ||||||||
| FaxNumber: | 7184459846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 01/10/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | MA62363 | NJ | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | MD.207369 | LA | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 226271-1 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 30033191 | 01 | KEYSTONE MERCY | OTHER | 010005160 | 01 | AMERICHOICE | OTHER | 5936559 | 01 | CIGNA | OTHER | 2377833 | 05 | LA | MEDICAID | 0000272 | 05 | NJ | MEDICAID | 1992518 | 01 | UNITED HEALTHCRE | OTHER | 951589 | 01 | PA | INDEPENDENCE BC | OTHER | 1249872 | 01 | PA | AETNA | OTHER | 1172691 | 01 | HORIZON NJ HEALTH | OTHER | 36650 | 01 | UNIVERSITY HEALTHPLAN | OTHER | 920007642 | 01 | RR MEDICARE | OTHER | P2800817 | 01 | OXFORD | OTHER | 2179915000 | 01 | AMERIHEALTH, KEYSTONE, IBC | OTHER | 3208581 | 01 | NJ | AETNA | OTHER |