Provider Demographics
NPI:1679795025
Name:PEDIATRIC HEALTHCARE
Entity Type:Organization
Organization Name:PEDIATRIC HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:THANDLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-945-0368
Mailing Address - Street 1:4039 RTE 219 SUITE 103
Mailing Address - Street 2:
Mailing Address - City:SALAMANCA
Mailing Address - State:NY
Mailing Address - Zip Code:14779-9625
Mailing Address - Country:US
Mailing Address - Phone:716-945-0368
Mailing Address - Fax:716-945-0757
Practice Address - Street 1:4039 RTE 219 SUITE 103
Practice Address - Street 2:
Practice Address - City:SALAMANCA
Practice Address - State:NY
Practice Address - Zip Code:14779-9625
Practice Address - Country:US
Practice Address - Phone:716-945-0368
Practice Address - Fax:716-945-0757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237701208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02056637Medicaid