Provider Demographics
NPI:1992801344
Name:FACELLE, THOMAS (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:FACELLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 GRAND ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1035
Mailing Address - Country:US
Mailing Address - Phone:845-987-3906
Mailing Address - Fax:845-987-5979
Practice Address - Street 1:257 LAFAYETTE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-4830
Practice Address - Country:US
Practice Address - Phone:845-369-8800
Practice Address - Fax:845-357-0086
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY145054208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
089D611OtherEMPIRE BLUE CROSS
08647OtherGHI HMO
0D3802OtherHEALTHNET NE
145054OtherHIP OF NY
4096594OtherAETNA TRADITIONAL
RS363OtherOXFORD
0002459OtherGHI
NY01015883Medicaid
0095911OtherAETNA HMO
RS363OtherOXFORD
4096594OtherAETNA TRADITIONAL