Provider Demographics
NPI:1063702710
Name:ALLIAD PEDIATRICS
Entity type:Organization
Organization Name:ALLIAD PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RPAC
Authorized Official - Prefix:
Authorized Official - First Name:MARYELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CASSIDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-775-4506
Mailing Address - Street 1:935 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:935 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5316
Practice Address - Country:US
Practice Address - Phone:516-466-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MD'S FOR KIDS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002298363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========OtherPRIVATE INSURANCE