1588651079 NPI number — BOSTON CHILDRENS HEALTH PHYSICIANS LLP

Table of content: MELISSA RENEE KEREKES MSW, LCSWA (NPI 1790400810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588651079 NPI number — BOSTON CHILDRENS HEALTH PHYSICIANS LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOSTON CHILDRENS HEALTH PHYSICIANS LLP
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:
BOSTON CHILDRENS HEALTH PHYSICIANS PEDIATRIC ENDOCRINOLOGY DIVISION
Provider Other Organization Name Type Code:
3
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:
1588651079
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 SUNSHINE COTTAGE RD # 1N-C08
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALHALLA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10595-1524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-593-1659
Provider Business Mailing Address Fax Number:
914-593-1790

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
755 N BROADWAY STE 400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SLEEPY HOLLOW
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-366-3400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
NEWMAN
Authorized Official First Name:
LEONARD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
914-594-4280

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , 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: 33D0681397 . This is a "CLIA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02729519 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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