Basic Information
| Provider Information | |||||||||
| NPI: | 1780684738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDIALE | ||||||||
| FirstName: | KOLO | ||||||||
| MiddleName: | NICHOLAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 68 HARRIS BUSHVILLE RD | ||||||||
| Address2: | |||||||||
| City: | HARRIS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457949864 | ||||||||
| FaxNumber: | 8457949868 | ||||||||
| Practice Location | |||||||||
| Address1: | 68 HARRIS BUSHVILLE ROAD | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457945335 | ||||||||
| FaxNumber: | 8457914136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 05/13/2016 | ||||||||
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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 | 207RE0101X | 220907 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 02155622 | 05 | NY | MEDICAID |