Provider Demographics
NPI:1508157215
Name:FALLSBURG PEDIATRICS PC
Entity Type:Organization
Organization Name:FALLSBURG PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ESTHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOTTLIEB
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:845-436-1850
Mailing Address - Street 1:142 LAUREL PARK RD
Mailing Address - Street 2:
Mailing Address - City:FALLSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12733-5009
Mailing Address - Country:US
Mailing Address - Phone:845-436-1850
Mailing Address - Fax:845-436-1851
Practice Address - Street 1:142 LAUREL PARK RD
Practice Address - Street 2:
Practice Address - City:FALLSBURG
Practice Address - State:NY
Practice Address - Zip Code:12733-5009
Practice Address - Country:US
Practice Address - Phone:845-436-1850
Practice Address - Fax:845-436-1851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-28
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333279208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02919359Medicaid