Provider Demographics
NPI:1760629232
Name:BLACK ROCK PEDIATRICS
Entity Type:Organization
Organization Name:BLACK ROCK PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-650-6030
Mailing Address - Street 1:1817 BLACK ROCK TPKE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3546
Mailing Address - Country:US
Mailing Address - Phone:203-337-5333
Mailing Address - Fax:203-337-5360
Practice Address - Street 1:1817 BLACK ROCK TPKE
Practice Address - Street 2:SUITE 206
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3546
Practice Address - Country:US
Practice Address - Phone:203-337-5333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-20
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037492208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty