Healthcare Provider Details

I. General information

NPI: 1942385299
Provider Name (Legal Business Name): BARDONIA PEDIATRIC ASSOC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 ROUTE 304
BARDONIA NY
10954-1617
US

IV. Provider business mailing address

446 ROUTE 304
BARDONIA NY
10954-1617
US

V. Phone/Fax

Practice location:
  • Phone: 845-623-8031
  • Fax: 845-624-0928
Mailing address:
  • Phone: 845-623-8031
  • Fax: 845-624-0928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. RONNIE KOSSOFF
Title or Position: BILLING MANAGER
Credential:
Phone: 845-623-8031