Organization
SHAKER PEDIATRICS PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. HENRY M NEILLEY MD (FIRST VICE PRESIDENT)
(518) 783-5563
Entity
Organization
Contact information
Practice address
10 CENTURY HILL DRIVE, LATHAM, NY 12110
(518) 783-5563
(518) 785-5708
Mailing address
10 CENTURY HILL DRIVE, LATHAM, NY 12110
(518) 783-5563
(518) 785-5708
Taxonomy
Speciality
Code
Description
License number
State
2080A0000X
Pediatric Adolescent Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000401340001
BS SHEELA GRANEY MD
—
01
—
000401387001
BS WILLIAM A PETERSEN MD
—
01
—
000401569001
BS HENRY NEILLEY MD
—
05
—
00392741
—
NY
05
—
00962767
—
NY
05
—
01260746
—
NY
05
—
01332856
—
NY
05
—
01762674
—
NY
05
—
02094695
—
NY
01
—
10001463
CDPHP HENRY NEILLEY MD
—
01
—
10002139
CDPHP MARYLA WARSZAWA-AMB
—
01
—
10002804
CDPHP WM A PETERSEN MD
—
01
—
10021167
CDPHP SHEELA GRANEY MD
—
01
—
10044836
CDPHP DAVID SHERWOOD MD
—
01
—
1007
CDPHP GROUP
—
01
—
26207
MVP HENRY NEILLEY MD
—
01
—
26208
MVP WILLIAM A PETERSEN MD
—
01
—
26210
MVP MARYLA WARSZAWA-AMB
—
01
—
349679
MVP DAVID SHERWOOD MD
—
01
—
964787
MVP SHEELA GRANEY MD
—
Enumeration date
08/02/2006
Last updated
08/22/2020
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