Organization
BRANCH PEDIATRICS AND ADOLESCENT GROUP P.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RICHARD C ANCONA MD (PRESIDENT)
(631) 979-6466
Entity
Organization
Contact information
Practice address
300 E MAIN ST, SUITE 4/5, SMITHTOWN, NY 11787-2900
(631) 979-6466
(631) 979-6475
Mailing address
300 E MAIN ST, SUITE 4/5, SMITHTOWN, NY 11787-2900
(631) 979-6466
(631) 979-6475
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
135693
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0121165
GHI
NY
01
—
2696288
GHI
NY
01
—
2837205
UNITED HEALTHCARE
NY
Enumeration date
02/02/2012
Last updated
02/02/2012
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