Provider Demographics
NPI:1174607014
Name:BASELICE, MARINO
Entity type:Individual
Prefix:
First Name:MARINO
Middle Name:
Last Name:BASELICE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:250 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-1420
Practice Address - Country:US
Practice Address - Phone:518-439-8077
Practice Address - Fax:518-439-8070
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY134658207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00555091Medicaid
NY00555091Medicaid
NY56093EMedicare PIN