NPIMap

Organization Active NPI

Tri State Eye Ophthalmology of Middletown PC

  • Specialist
  • Middletown, NY
National Provider Identifier
1053430256
Registry record updated Jan 30, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
License
MD049303L Issued in NY
Legal business name
TRI STATE EYE OPHTHALMOLOGY OF MIDDLETOWN PC
Doing business as
Tri State Eye Ophthalmology of Middletown PC
Practice address
75 Crystal Run Rd
Suite 120
Middletown, NY 10941-7000
Phone
(845) 703-2020
Fax
(845) 703-2901
NPI assigned
Mar 28, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 30, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Severin Bohdan Palydowycz, MDNPI 1215939483
Title
Owner
Phone
(570) 296-9696

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X SINGLE SPECIALTY GROUP 174400000X MD049303L NY Primary

Addresses

Primary practice location

75 Crystal Run Rd
Suite 120
Middletown, NY 10941-7000

Mailing address

75 Crystal Run Rd
Suite 120
Middletown, NY 10941-7000
Phone (845) 703-2020

Other names 1

  • Tri State Eye Ophthalmology of Middletown PC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY, NJ2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040318000485 NY Part B Supplier - Clinic/Group Practice 3476443995 Receives reassigned benefits from 5 practitioners
Practice locations: Middletown, NY
O20251021000047 NJ Part B Supplier - Clinic/Group Practice 3476443995 Receives reassigned benefits from 1 practitioner
Practice locations: Fair Lawn, NJ

National Provider Directory

National Provider Directory

Locations

18-01 Pollitt Dr
Ste 4
Fair Lawn, NJ 07410
Phone (201) 414-5649

75 Crystal Run Rd
Ste 120
Middletown, NY 10941
Phone (845) 703-2020

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1175040000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1422576000000",
    "number": "1053430256",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "75 CRYSTAL RUN RD",
            "address_2": "SUITE 120",
            "city": "MIDDLETOWN",
            "state": "NY",
            "postal_code": "109417000",
            "telephone_number": "845-703-2020",
            "fax_number": "845-703-2901"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "75 CRYSTAL RUN RD",
            "address_2": "SUITE 120",
            "city": "MIDDLETOWN",
            "state": "NY",
            "postal_code": "109417000",
            "telephone_number": "845-703-2020",
            "fax_number": "845-703-2901"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRI STATE EYE OPHTHALMOLOGY OF MIDDLETOWN PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-28",
        "last_updated": "2015-01-30",
        "status": "A",
        "authorized_official_last_name": "PALYDOWYCZ",
        "authorized_official_first_name": "SEVERIN",
        "authorized_official_middle_name": "BOHDAN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "570-296-9696",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": "NY",
            "license": "MD049303L",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Tri State Eye Ophthalmology of Middletown PC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Middletown, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 30, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.