Organization
EDISON R. BLANCO PHYSICIAN PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
EDISON ROQUE BLANCO (OWNER)
(631) 969-7875
Entity
Organization
Contact information
Practice address
16 BRENTWOOD RD, BAY SHORE, NY 11706-8011
(631) 969-7875
Mailing address
16 BRENTWOOD RD, BAY SHORE, NY 11706-8011
(631) 969-7875
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
189607
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01634335
—
NY
Enumeration date
06/02/2008
Last updated
09/08/2008
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