Provider Demographics
NPI:1902884463
Name:BIALECKI, PHILLIPH (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIPH
Middle Name:
Last Name:BIALECKI
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 1:3804 KISMET LAKES LN
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33993-3310
Mailing Address - Country:US
Mailing Address - Phone:614-975-2299
Mailing Address - Fax:
Practice Address - Street 1:3600 S HIGHLANDS AVE
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-5416
Practice Address - Country:US
Practice Address - Phone:863-385-6101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-067466207P00000X
FLME158083207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000553736OtherANTHEM BLUE CROSS
OH0992752Medicaid
OH000000538267OtherANTHEM BLUE CROSS
OHP00447635OtherMEDICARE RR
OHP00643561Medicare PIN
OH000000553736OtherANTHEM BLUE CROSS
OH000000538267OtherANTHEM BLUE CROSS
OH0992752Medicaid
OH4192321Medicare PIN
OH4192322Medicare PIN