Provider Demographics
NPI:1821178682
Name:NEWTONVILLE PEDIATRICS & INTERNAL MEDICINE
Entity Type:Organization
Organization Name:NEWTONVILLE PEDIATRICS & INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FOGARTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-783-1445
Mailing Address - Street 1:564 NEW LOUDON RD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-5336
Mailing Address - Country:US
Mailing Address - Phone:518-783-1445
Mailing Address - Fax:518-783-4622
Practice Address - Street 1:564 NEW LOUDON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-5336
Practice Address - Country:US
Practice Address - Phone:518-783-1445
Practice Address - Fax:518-783-4622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195064261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service