Provider Demographics
NPI:1770620163
Name:THE PEDIATRIC SPECIALTY PRACTICES OF THE GREATER HUDSON VALLEY
Entity type:Organization
Organization Name:THE PEDIATRIC SPECIALTY PRACTICES OF THE GREATER HUDSON VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:D
Authorized Official - Last Name:FETHKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-703-7000
Mailing Address - Street 1:75 CRYSTAL RUN RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-7000
Mailing Address - Country:US
Mailing Address - Phone:845-703-7000
Mailing Address - Fax:845-703-0160
Practice Address - Street 1:75 CRYSTAL RUN RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-7000
Practice Address - Country:US
Practice Address - Phone:845-703-7000
Practice Address - Fax:845-703-0160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195450-12080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01488655Medicaid