Provider Demographics
NPI:1023523602
Name:PAGODA MEDICAL PC
Entity type:Organization
Organization Name:PAGODA MEDICAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ANATOLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHNAYDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-933-9089
Mailing Address - Street 1:3412 AVENUE T
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4913
Mailing Address - Country:US
Mailing Address - Phone:347-933-9089
Mailing Address - Fax:
Practice Address - Street 1:3412 AVENUE T
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4913
Practice Address - Country:US
Practice Address - Phone:347-933-9089
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-05
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY275175208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03982363Medicaid