Basic Information
| Provider Information | |||||||||
| NPI: | 1285156067 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PELHAM PKWY MEDICAL OF NEW YORK LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 304 WAINWRIGHT DR | ||||||||
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| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600621900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472571244 | ||||||||
| FaxNumber: | 2242468042 | ||||||||
| Practice Location | |||||||||
| Address1: | 2157 WHITE PLAINS RD | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104621405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183011100 | ||||||||
| FaxNumber: | 2242468042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2017 | ||||||||
| LastUpdateDate: | 06/04/2020 | ||||||||
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| AuthorizedOfficialLastName: | ALMEDA | ||||||||
| AuthorizedOfficialFirstName: | AMI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2243180118 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036113246 | 05 | IL | MEDICAID |