Provider Demographics
NPI:1568731198
Name:CORTELYOU ROAD PEDIATRICS
Entity Type:Organization
Organization Name:CORTELYOU ROAD PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JMAES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:GOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-282-0170
Mailing Address - Street 1:1103 CORTELYOU RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-5303
Mailing Address - Country:US
Mailing Address - Phone:718-282-0170
Mailing Address - Fax:718-282-1008
Practice Address - Street 1:1103 CORTELYOU RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-5303
Practice Address - Country:US
Practice Address - Phone:718-282-0170
Practice Address - Fax:718-282-1008
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JAMES W GOUGH, M.D.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY137428208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty