Provider Demographics
NPI:1629177134
Name:LEWISTON VILLAGE PEDIATRICS
Entity Type:Organization
Organization Name:LEWISTON VILLAGE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:P
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-754-7337
Mailing Address - Street 1:733 CENTER STREET
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:NY
Mailing Address - Zip Code:14092
Mailing Address - Country:US
Mailing Address - Phone:716-754-7337
Mailing Address - Fax:716-754-2041
Practice Address - Street 1:733 CENTER STREET
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092
Practice Address - Country:US
Practice Address - Phone:716-754-7337
Practice Address - Fax:716-754-2041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY131077208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07152689Medicaid
NY00968483Medicaid
NY01827458Medicaid
NY00586883Medicaid