Provider Demographics
NPI:1609065390
Name:PEDIATRIC ENT ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:PEDIATRIC ENT ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:SUSAN
Authorized Official - Last Name:BRODSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:716-362-9730
Mailing Address - Street 1:651 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-1051
Mailing Address - Country:US
Mailing Address - Phone:716-362-9729
Mailing Address - Fax:
Practice Address - Street 1:3580 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1645
Practice Address - Country:US
Practice Address - Phone:716-362-9730
Practice Address - Fax:716-362-9729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008898-1363A00000X
NY010010-1363A00000X
NY276298363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========Medicaid
NY=========Medicare UPIN