Provider Demographics
NPI:1588765952
Name:LONG POND PEDIATRICS
Entity type:Organization
Organization Name:LONG POND PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARYANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIERNAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-225-0950
Mailing Address - Street 1:3 SAREDON PLACE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14606
Mailing Address - Country:US
Mailing Address - Phone:585-225-0950
Mailing Address - Fax:585-225-9093
Practice Address - Street 1:3 SAREDON PLACE
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14606
Practice Address - Country:US
Practice Address - Phone:585-225-0950
Practice Address - Fax:585-225-9093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02223729Medicaid