Healthcare Provider Details

I. General information

NPI: 1417967514
Provider Name (Legal Business Name): NICHOLAS GEORGE BAMBINO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 05/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 ELM ST
CORNWALL NY
12518
US

IV. Provider business mailing address

10 ELM ST
CORNWALL NY
12518
US

V. Phone/Fax

Practice location:
  • Phone: 845-534-7080
  • Fax: 845-534-4171
Mailing address:
  • Phone: 845-534-7080
  • Fax: 845-534-4171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number116053
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number116053
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: