Provider Demographics
NPI:1255580445
Name:CHILD CARE PEDIATRICS, P.C.
Entity type:Organization
Organization Name:CHILD CARE PEDIATRICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELEONORA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEZHERITSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-463-6581
Mailing Address - Street 1:6553 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-7028
Mailing Address - Country:US
Mailing Address - Phone:718-366-5391
Mailing Address - Fax:718-418-3367
Practice Address - Street 1:6553 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-7028
Practice Address - Country:US
Practice Address - Phone:718-366-5391
Practice Address - Fax:718-418-3367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215450174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02271621Medicaid