Provider Demographics
NPI:1336156223
Name:SHAKER PEDIATRICS PC
Entity Type:Organization
Organization Name:SHAKER PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FIRST VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:NEILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-783-5563
Mailing Address - Street 1:10 CENTURY HILL DRIVE
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110
Mailing Address - Country:US
Mailing Address - Phone:518-783-5563
Mailing Address - Fax:518-785-5708
Practice Address - Street 1:10 CENTURY HILL DRIVE
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110
Practice Address - Country:US
Practice Address - Phone:518-783-5563
Practice Address - Fax:518-785-5708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01762674Medicaid
26210OtherMVP MARYLA WARSZAWA-AMB
000401340001OtherBS SHEELA GRANEY MD
NY01260746Medicaid
26208OtherMVP WILLIAM A PETERSEN MD
000401387001OtherBS WILLIAM A PETERSEN MD
10002804OtherCDPHP WM A PETERSEN MD
26207OtherMVP HENRY NEILLEY MD
000401569001OtherBS HENRY NEILLEY MD
10001463OtherCDPHP HENRY NEILLEY MD
10044836OtherCDPHP DAVID SHERWOOD MD
964787OtherMVP SHEELA GRANEY MD
NY00392741Medicaid
349679OtherMVP DAVID SHERWOOD MD
10002139OtherCDPHP MARYLA WARSZAWA-AMB
10021167OtherCDPHP SHEELA GRANEY MD
NY00962767Medicaid
NY01332856Medicaid
NY02094695Medicaid
1007OtherCDPHP GROUP