Provider Demographics
NPI:1861626210
Name:VILLAGE PEDIATRIC GROUP PLLC
Entity Type:Organization
Organization Name:VILLAGE PEDIATRIC GROUP PLLC
Other - Org Name:VILLAGE PEDIATRIC GROUP PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-771-7070
Mailing Address - Street 1:115 MAIN ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:TUCKAHOE
Mailing Address - State:NY
Mailing Address - Zip Code:10707-2911
Mailing Address - Country:US
Mailing Address - Phone:914-771-7070
Mailing Address - Fax:914-771-7073
Practice Address - Street 1:115 MAIN ST
Practice Address - Street 2:SUITE 301
Practice Address - City:TUCKAHOE
Practice Address - State:NY
Practice Address - Zip Code:10707-2911
Practice Address - Country:US
Practice Address - Phone:914-771-7070
Practice Address - Fax:914-771-7073
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VILLAGE PEDIATRIC GROUP PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216946208000000X
NY225800208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty