1336156223 NPI number — SHAKER PEDIATRICS PC

Table of content: (NPI 1336156223)

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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