Provider Demographics
NPI:1275724767
Name:BOSTON PEDIATRICS, PLLC
Entity type:Organization
Organization Name:BOSTON PEDIATRICS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:CORNIELLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-617-2500
Mailing Address - Street 1:1262 BOSTON RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-3602
Mailing Address - Country:US
Mailing Address - Phone:718-617-2500
Mailing Address - Fax:718-617-0500
Practice Address - Street 1:1262 BOSTON RD
Practice Address - Street 2:SUITE 1
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-3602
Practice Address - Country:US
Practice Address - Phone:718-617-2500
Practice Address - Fax:718-617-0500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214716208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03426235Medicaid
NV02087341Medicaid
NY03305057Medicaid
NY02269730Medicaid