1336156223 NPI number — SHAKER PEDIATRICS PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336156223 NPI number — SHAKER PEDIATRICS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHAKER PEDIATRICS PC
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:
1336156223
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 CENTURY HILL DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LATHAM
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-783-5563
Provider Business Mailing Address Fax Number:
518-785-5708

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 CENTURY HILL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LATHAM
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-783-5563
Provider Business Practice Location Address Fax Number:
518-785-5708
Provider Enumeration Date:
08/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NEILLEY
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
FIRST VICE PRESIDENT
Authorized Official Telephone Number:
518-783-5563

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01762674 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 26210 . This is a "MVP MARYLA WARSZAWA-AMB" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000401340001 . This is a "BS SHEELA GRANEY MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01260746 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 26208 . This is a "MVP WILLIAM A PETERSEN MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000401387001 . This is a "BS WILLIAM A PETERSEN MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10002804 . This is a "CDPHP WM A PETERSEN MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 26207 . This is a "MVP HENRY NEILLEY MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000401569001 . This is a "BS HENRY NEILLEY MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10001463 . This is a "CDPHP HENRY NEILLEY MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10044836 . This is a "CDPHP DAVID SHERWOOD MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 964787 . This is a "MVP SHEELA GRANEY MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00392741 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 349679 . This is a "MVP DAVID SHERWOOD MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10002139 . This is a "CDPHP MARYLA WARSZAWA-AMB" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10021167 . This is a "CDPHP SHEELA GRANEY MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00962767 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01332856 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02094695 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1007 . This is a "CDPHP GROUP" identifier . This identifiers is of the category "OTHER".




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