1215205893 NPI number — IN TOWN PEDIATRICS, PLLC

Table of content: (NPI 1215205893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215205893 NPI number — IN TOWN PEDIATRICS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IN TOWN PEDIATRICS, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215205893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 PURCHASE ST
Provider Second Line Business Mailing Address:
SUITE 8A
Provider Business Mailing Address City Name:
RYE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10580-2141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-967-9000
Provider Business Mailing Address Fax Number:
914-967-9007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 PURCHASE ST
Provider Second Line Business Practice Location Address:
SUITE 8A
Provider Business Practice Location Address City Name:
RYE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10580-2141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-967-9000
Provider Business Practice Location Address Fax Number:
914-967-9007
Provider Enumeration Date:
12/09/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GAZZOLA-KRAENZLIN
Authorized Official First Name:
ELENA
Authorized Official Middle Name:
ERIKA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
914-967-9000

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  040193 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X , with the licence number: 215407 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02159204 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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