Provider Demographics
NPI:1639233307
Name:SOUTH ISLAND PEDIATRICS, P.C.
Entity Type:Organization
Organization Name:SOUTH ISLAND PEDIATRICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:I
Authorized Official - Last Name:WEILER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-569-0500
Mailing Address - Street 1:86 CARMAN AVE
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-1905
Mailing Address - Country:US
Mailing Address - Phone:516-569-0500
Mailing Address - Fax:516-569-0570
Practice Address - Street 1:86 CARMAN AVE
Practice Address - Street 2:
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516-1905
Practice Address - Country:US
Practice Address - Phone:516-569-0500
Practice Address - Fax:516-569-0570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY148634261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00890588Medicaid
NYB20216Medicare UPIN