Provider Demographics
NPI:1518417120
Name:AVENUE U PEDIATRICS, PC
Entity Type:Organization
Organization Name:AVENUE U PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BASSOUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-376-4636
Mailing Address - Street 1:2149 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-4038
Mailing Address - Country:US
Mailing Address - Phone:718-376-4636
Mailing Address - Fax:718-376-4635
Practice Address - Street 1:2149 E 5TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-4038
Practice Address - Country:US
Practice Address - Phone:718-376-4636
Practice Address - Fax:718-376-4635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223690208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2255310Medicaid