Healthcare Provider Details

I. General information

NPI: 1518989193
Provider Name (Legal Business Name): PEDIATRIC UROLOGY ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 WHITE PLAINS RD SUITE 306
TARRYTOWN NY
10591-5535
US

IV. Provider business mailing address

247 ROUTE 100 SUITE 1002
SOMERS NY
10589-3231
US

V. Phone/Fax

Practice location:
  • Phone: 914-493-8628
  • Fax: 914-493-8564
Mailing address:
  • Phone: 914-962-8290
  • Fax: 914-962-8851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number149688
License Number StateNY

VIII. Authorized Official

Name: DR. EDWARD F REDA
Title or Position: PRESIDENT- MD
Credential: MD
Phone: 914-962-8290