Provider Demographics
NPI:1003968918
Name:CLARKSTOWN PULMONARY ASSOCIATES PC
Entity Type:Organization
Organization Name:CLARKSTOWN PULMONARY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:PELLICONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-786-4060
Mailing Address - Street 1:51-55 ROUTE 9W
Mailing Address - Street 2:
Mailing Address - City:WEST HAVERSTRAW
Mailing Address - State:NY
Mailing Address - Zip Code:10993-1912
Mailing Address - Country:US
Mailing Address - Phone:845-786-4060
Mailing Address - Fax:845-786-4066
Practice Address - Street 1:51-55 ROUTE 9W
Practice Address - Street 2:
Practice Address - City:WEST HAVERSTRAW
Practice Address - State:NY
Practice Address - Zip Code:10993-1912
Practice Address - Country:US
Practice Address - Phone:845-786-4060
Practice Address - Fax:845-786-4066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01243741Medicaid
NY01243741Medicaid