=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336336486
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACADEMY PEDIATRICS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2007
-----------------------------------------------------
Last Update Date | 10/02/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 KILMER DR
-----------------------------------------------------
City | MORGANVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07751-1564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-617-8888
-----------------------------------------------------
Fax | 732-617-8880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 KILMER DR
-----------------------------------------------------
City | MORGANVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07751-1564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-617-8888
-----------------------------------------------------
Fax | 732-617-8880
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. YULIYA BAKSHIYEV
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 732-617-8888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MA64214
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------