Provider Demographics
NPI:1154408300
Name:LIBERTY PEDIATRICS PC
Entity type:Organization
Organization Name:LIBERTY PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARSHAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:TRIVEDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-292-6684
Mailing Address - Street 1:39 OLD MONTICELLO RD
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:NY
Mailing Address - Zip Code:12754
Mailing Address - Country:US
Mailing Address - Phone:845-292-6684
Mailing Address - Fax:845-292-6770
Practice Address - Street 1:39 OLD MONTICELLO RD
Practice Address - Street 2:CATSKILL PROF PLAZA
Practice Address - City:FERNDALE
Practice Address - State:NY
Practice Address - Zip Code:12754
Practice Address - Country:US
Practice Address - Phone:845-292-6684
Practice Address - Fax:845-292-6770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY178764208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01131213Medicaid
E20411Medicare UPIN