Provider Demographics
NPI:1366735862
Name:RICHMOND HILL PEDIATRIC ASSOCIATES
Entity type:Organization
Organization Name:RICHMOND HILL PEDIATRIC ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:ELIANA
Authorized Official - Last Name:WALLACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-850-9225
Mailing Address - Street 1:8604 117TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-1713
Mailing Address - Country:US
Mailing Address - Phone:718-850-9225
Mailing Address - Fax:718-850-9226
Practice Address - Street 1:8604 117TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-1713
Practice Address - Country:US
Practice Address - Phone:718-850-9225
Practice Address - Fax:718-850-9226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2242972080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02244920Medicaid
NY224297OtherSTATE LICENSE