MEDICARE: DR. LISA R BEVILACQUA D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	191889	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	08954	OTHER	NY	MVP
3	200032	OTHER	NY	SENIOR WHOLE HEALTH
4	52558	OTHER	NY	GHI/HMO
5	10005959	OTHER	NY	CDPHP
6	000401405003	OTHER	NY	BSNENY
7	040824000041	OTHER	NY	FIDELIS
8	4725D1	OTHER	NY	EMPIRE BC
9	531715	OTHER	NY	AETNA

General Provider Information

NPI Number	:	1336231844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA R BEVILACQUA D.O.

Provider Business Mailing Address
First Line	:	711 TROY SCHENECTADY RD STE 203
Second Line	:
City	:	LATHAM
State	:	NY
Zip	:	12110-2461
Country	:	US
Telephone Number	:	518-782-3700
Fax Number	:	518-782-3799

Provider Business Practice Location Address
First Line	:	1882 NEW SCOTLAND RD STE 200
Second Line	:
City	:	SLINGERLANDS
State	:	NY
Zip	:	12159-3627
Country	:	US
Telephone Number	:	518-439-2460
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2006
Last Update Date	:	05/07/2021

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