Provider Demographics
NPI:1679010391
Name:GREAT NECK PEDIATRIC ASSOCIATES, PC
Entity Type:Organization
Organization Name:GREAT NECK PEDIATRIC ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GILBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-487-4020
Mailing Address - Street 1:173 EAST SHORE RD
Mailing Address - Street 2:202
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023
Mailing Address - Country:US
Mailing Address - Phone:516-487-4020
Mailing Address - Fax:516-487-4039
Practice Address - Street 1:173 E SHORE RD
Practice Address - Street 2:202
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11023-2415
Practice Address - Country:US
Practice Address - Phone:516-487-4020
Practice Address - Fax:516-487-4039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG28691Medicare UPIN
NYA65120Medicare UPIN
NYC05268Medicare UPIN