Provider Demographics
NPI:1598729808
Name:ALLENTOWN PEDIATRIC AND ADOLESCENT MEDICINE
Entity Type:Organization
Organization Name:ALLENTOWN PEDIATRIC AND ADOLESCENT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:
Authorized Official - Last Name:EHLENFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-332-4472
Mailing Address - Street 1:560 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-1110
Mailing Address - Country:US
Mailing Address - Phone:716-332-4472
Mailing Address - Fax:716-332-4675
Practice Address - Street 1:560 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-1110
Practice Address - Country:US
Practice Address - Phone:716-332-4472
Practice Address - Fax:716-332-4675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02374692Medicaid
NY02374692Medicaid