Provider Demographics
NPI:1649303058
Name:PEDIATRIC ASSOCIATES OF PUTNAM
Entity type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF PUTNAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-279-9652
Mailing Address - Street 1:667 STONELEIGH AVE
Mailing Address - Street 2:SUITE 116
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-2454
Mailing Address - Country:US
Mailing Address - Phone:845-279-9652
Mailing Address - Fax:845-279-3606
Practice Address - Street 1:667 STONELEIGH AVE
Practice Address - Street 2:SUITE 116
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512-2454
Practice Address - Country:US
Practice Address - Phone:845-279-9652
Practice Address - Fax:845-279-3606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1112852080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty