Provider Demographics
NPI:1942385299
Name:BARDONIA PEDIATRIC ASSOC
Entity Type:Organization
Organization Name:BARDONIA PEDIATRIC ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSSOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-623-8031
Mailing Address - Street 1:446 ROUTE 304
Mailing Address - Street 2:
Mailing Address - City:BARDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:10954-1617
Mailing Address - Country:US
Mailing Address - Phone:845-623-8031
Mailing Address - Fax:845-624-0928
Practice Address - Street 1:446 ROUTE 304
Practice Address - Street 2:
Practice Address - City:BARDONIA
Practice Address - State:NY
Practice Address - Zip Code:10954-1617
Practice Address - Country:US
Practice Address - Phone:845-623-8031
Practice Address - Fax:845-624-0928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00520223Medicaid