Provider Demographics
NPI:1366697385
Name:REGIONAL GYNECOLOGIC ONCOLOGY
Entity type:Organization
Organization Name:REGIONAL GYNECOLOGIC ONCOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:EPHRAIM
Authorized Official - Middle Name:
Authorized Official - Last Name:RESNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-354-6262
Mailing Address - Street 1:PO BOX 26040
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31221-6040
Mailing Address - Country:US
Mailing Address - Phone:478-475-1299
Mailing Address - Fax:478-405-7928
Practice Address - Street 1:2 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-3516
Practice Address - Country:US
Practice Address - Phone:845-354-6262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214871207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD38175Medicare PIN
NY53Z451Medicare PIN