Provider Demographics
NPI:1609994748
Name:WEST 11 STREET PEDIATRICS
Entity Type:Organization
Organization Name:WEST 11 STREET PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:EDIT
Authorized Official - Middle Name:
Authorized Official - Last Name:POLYAKOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-529-4330
Mailing Address - Street 1:46 WEST 11 STREET
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:46 W 11TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8602
Practice Address - Country:US
Practice Address - Phone:212-529-4330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty