Provider Demographics
NPI:1376594663
Name:WOMENS OB GYN CARE AT THE PAVILION PC
Entity Type:Organization
Organization Name:WOMENS OB GYN CARE AT THE PAVILION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:LAFONTANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-446-6401
Mailing Address - Street 1:3250 WESTCHESTER AVE
Mailing Address - Street 2:SUITE 111-112
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-4500
Mailing Address - Country:US
Mailing Address - Phone:718-231-7900
Mailing Address - Fax:
Practice Address - Street 1:3250 WESTCHESTER AVE
Practice Address - Street 2:SUITE 111-112
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-4500
Practice Address - Country:US
Practice Address - Phone:718-231-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY145497207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWYTYP1Medicare PIN