Provider Demographics
NPI:1740552942
Name:BRANCH PEDIATRICS AND ADOLESCENT GROUP P.C.
Entity type:Organization
Organization Name:BRANCH PEDIATRICS AND ADOLESCENT GROUP P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:ANCONA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-979-6466
Mailing Address - Street 1:300 E MAIN ST
Mailing Address - Street 2:SUITE 4/5
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2900
Mailing Address - Country:US
Mailing Address - Phone:631-979-6466
Mailing Address - Fax:631-979-6475
Practice Address - Street 1:300 E MAIN ST
Practice Address - Street 2:SUITE 4/5
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2900
Practice Address - Country:US
Practice Address - Phone:631-979-6466
Practice Address - Fax:631-979-6475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135693208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2837205OtherUNITED HEALTHCARE
NY0121165OtherGHI
NY2696288OtherGHI
NY0121165OtherGHI