Provider Demographics
NPI:1083815385
Name:ADVANCED PEDIATRICS, PC
Entity Type:Organization
Organization Name:ADVANCED PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILFREDO
Authorized Official - Middle Name:
Authorized Official - Last Name:LAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-271-2600
Mailing Address - Street 1:9436 59TH AVE
Mailing Address - Street 2:SUITE C4
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-5151
Mailing Address - Country:US
Mailing Address - Phone:718-271-2600
Mailing Address - Fax:718-271-2766
Practice Address - Street 1:9436 59TH AVE
Practice Address - Street 2:SUITE C4
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5151
Practice Address - Country:US
Practice Address - Phone:718-271-2600
Practice Address - Fax:718-271-2766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211204208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01922430Medicaid
NY01860195Medicaid