Provider Demographics
NPI:1518989193
Name:PEDIATRIC UROLOGY ASSOCIATES, PC
Entity Type:Organization
Organization Name:PEDIATRIC UROLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT- MD
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:F
Authorized Official - Last Name:REDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-962-8290
Mailing Address - Street 1:247 ROUTE 100
Mailing Address - Street 2:SUITE 1002
Mailing Address - City:SOMERS
Mailing Address - State:NY
Mailing Address - Zip Code:10589-3231
Mailing Address - Country:US
Mailing Address - Phone:914-962-8290
Mailing Address - Fax:914-962-8851
Practice Address - Street 1:150 WHITE PLAINS RD
Practice Address - Street 2:SUITE 306
Practice Address - City:TARRYTOWN
Practice Address - State:NY
Practice Address - Zip Code:10591-5535
Practice Address - Country:US
Practice Address - Phone:914-493-8628
Practice Address - Fax:914-493-8564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1496882088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01898273Medicaid
NY=========OtherTAX IDENTIFIER
NYW5D411Medicare ID - Type UnspecifiedGROUP NUMBER