Provider Demographics
NPI:1619105954
Name:GARNERVILLE PEDIATRICS
Entity Type:Organization
Organization Name:GARNERVILLE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:F
Authorized Official - Last Name:COONEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:845-271-4794
Mailing Address - Street 1:124 RAMAPO RD
Mailing Address - Street 2:
Mailing Address - City:GARNERVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10923-1571
Mailing Address - Country:US
Mailing Address - Phone:845-271-4794
Mailing Address - Fax:845-271-4795
Practice Address - Street 1:124 RAMAPO RD
Practice Address - Street 2:
Practice Address - City:GARNERVILLE
Practice Address - State:NY
Practice Address - Zip Code:10923-1571
Practice Address - Country:US
Practice Address - Phone:845-271-4794
Practice Address - Fax:845-271-4795
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NYACK PEDIATRIC ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1930322080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01827421Medicaid