Basic Information
| Provider Information | |||||||||
| NPI: | 1306233408 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIRIAM GORDON PEDIATRIC NP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 302 MANOR RD | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103142408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188151000 | ||||||||
| FaxNumber: | 7188158122 | ||||||||
| Practice Location | |||||||||
| Address1: | 6010 BAY PKWY FL 9 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112046079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182382100 | ||||||||
| FaxNumber: | 7188158122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2015 | ||||||||
| LastUpdateDate: | 04/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | GORDON | ||||||||
| AuthorizedOfficialFirstName: | MIRIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 7188151000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 381940 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 02460364 | 05 | NY | MEDICAID |