Provider Demographics
NPI:1639478340
Name:BAYSIDE PEDIATRIC CARE P.C.
Entity Type:Organization
Organization Name:BAYSIDE PEDIATRIC CARE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LI-MIN
Authorized Official - Middle Name:
Authorized Official - Last Name:YANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-465-5888
Mailing Address - Street 1:22116 UNION TPKE
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11364-3641
Mailing Address - Country:US
Mailing Address - Phone:718-465-5888
Mailing Address - Fax:718-465-5889
Practice Address - Street 1:22116 UNION TPKE
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11364-3641
Practice Address - Country:US
Practice Address - Phone:718-465-5888
Practice Address - Fax:718-465-5889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-21
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY240002208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02824739Medicaid