Provider Demographics
NPI:1467968834
Name:KOLESNIKOV PEDIATRICS PLLC
Entity Type:Organization
Organization Name:KOLESNIKOV PEDIATRICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLESNIKOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-565-9500
Mailing Address - Street 1:PO BOX 60623
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-0623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 PONDEROSA DR
Practice Address - Street 2:
Practice Address - City:JENKINS
Practice Address - State:KY
Practice Address - Zip Code:41537
Practice Address - Country:US
Practice Address - Phone:980-565-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY287701261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center