Provider Demographics
NPI:1972926814
Name:WYCKOFF PEDIATRIC CARE CENTER
Entity Type:Organization
Organization Name:WYCKOFF PEDIATRIC CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VALI
Authorized Official - Middle Name:
Authorized Official - Last Name:GACHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-240-1795
Mailing Address - Street 1:1411 MYRTLE AVE
Mailing Address - Street 2:WYCKOFF PEDIATRIC CARE CENTER
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-4512
Mailing Address - Country:US
Mailing Address - Phone:718-907-4301
Mailing Address - Fax:718-919-1309
Practice Address - Street 1:1411 MYRTLE AVE
Practice Address - Street 2:1411 MYRTLE AVENUE
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4512
Practice Address - Country:US
Practice Address - Phone:718-907-4301
Practice Address - Fax:718-919-1309
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WYCKOFF PROFESSIONAL MEDICAL SERVICES PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-29
Last Update Date:2019-04-02
Deactivation Date:2015-06-29
Deactivation Code:
Reactivation Date:2015-06-29
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03722025Medicaid
NY03722025Medicaid