Basic Information
| Provider Information | |||||||||
| NPI: | 1740467737 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ACHILDIEV | ||||||||
| FirstName: | FREDERICK | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | BAY SHORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117067381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315814400 | ||||||||
| FaxNumber: | 6312773750 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | BAY SHORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117067381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315814400 | ||||||||
| FaxNumber: | 6312773750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2008 | ||||||||
| LastUpdateDate: | 12/02/2009 | ||||||||
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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 | 208600000X | 242230 | NY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 242230 | 01 | NY | LICENSE | OTHER | 02957468 | 05 | NY | MEDICAID |