Provider Demographics
NPI:1982093944
Name:FAMILY PEDIATRIC
Entity Type:Organization
Organization Name:FAMILY PEDIATRIC
Other - Org Name:FAMILY PEDIATRIC
Other - Org Type:Other Name
Authorized Official - Title/Position:REGISTERED NURSE
Authorized Official - Prefix:
Authorized Official - First Name:OLUWAKEMI
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUNDALU
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE
Authorized Official - Phone:347-683-0924
Mailing Address - Street 1:2224 COLLIER AVE
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2637
Mailing Address - Country:US
Mailing Address - Phone:347-683-0924
Mailing Address - Fax:516-596-8860
Practice Address - Street 1:2224 COLLIER AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-2637
Practice Address - Country:US
Practice Address - Phone:347-683-0924
Practice Address - Fax:516-596-8860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY689977251J00000X, 282NC2000X, 302R00000X, 313M00000X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren
No251J00000XAgenciesNursing Care
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========Medicaid