Basic Information
| Provider Information | |||||||||
| NPI: | 1437494523 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CANDID MEDICAL CENTER, LLC | ||||||||
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| Address1: | 500 W MAIN ST | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | BABYLON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117023027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319305215 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6525 PROFESSIONAL PL | ||||||||
| Address2: | SUITE C | ||||||||
| City: | RIVERDALE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302742519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709941250 | ||||||||
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| ProviderEnumerationDate: | 11/30/2012 | ||||||||
| LastUpdateDate: | 11/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | PYKO | ||||||||
| AuthorizedOfficialFirstName: | BODO | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7709941250 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.