Healthcare Provider Details

I. General information

NPI: 1649303058
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF PUTNAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 11/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

667 STONELEIGH AVE SUITE 116
CARMEL NY
10512-2454
US

IV. Provider business mailing address

667 STONELEIGH AVE SUITE 116
CARMEL NY
10512-2454
US

V. Phone/Fax

Practice location:
  • Phone: 845-279-9652
  • Fax: 845-279-3606
Mailing address:
  • Phone: 845-279-9652
  • Fax: 845-279-3606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number111285
License Number StateNY

VIII. Authorized Official

Name: MRS. SUZANNE BENNIE
Title or Position: MEDICAL BILLER
Credential:
Phone: 845-279-9652