Basic Information
| Provider Information | |||||||||
| NPI: | 1750466108 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RACINE | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | MD,PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1621 EASTCHESTER RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104612604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184058040 | ||||||||
| FaxNumber: | 7184058048 | ||||||||
| Practice Location | |||||||||
| Address1: | 1621 EASTCHESTER RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104612604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184058040 | ||||||||
| FaxNumber: | 7184058048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 02/02/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 166683 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01062353 | 05 | NY | MEDICAID |