Provider Demographics
NPI:1306917687
Name:GOUVERNEUR PEDIATRICS,PC
Entity type:Organization
Organization Name:GOUVERNEUR PEDIATRICS,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF PROF.CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:C
Authorized Official - Last Name:SCHUESSLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:315-287-4440
Mailing Address - Street 1:77 W BARNEY ST
Mailing Address - Street 2:PHYSICIAN BLDG. STE.C
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642-1040
Mailing Address - Country:US
Mailing Address - Phone:315-287-4440
Mailing Address - Fax:315-287-1858
Practice Address - Street 1:77 W BARNEY ST
Practice Address - Street 2:PHYSICIAN BLDG. STE.C
Practice Address - City:GOUVERNEUR
Practice Address - State:NY
Practice Address - Zip Code:13642-1040
Practice Address - Country:US
Practice Address - Phone:315-287-4440
Practice Address - Fax:315-287-1858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY156955174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY39351AMedicare ID - Type UnspecifiedGROUP # FOR P.C.