NPIMap

Organization Active NPI

Shaker Pediatrics PC

  • Pediatric Adolescent Medicine Physician
  • Latham, NY
National Provider Identifier
1336156223
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric Adolescent Medicine PhysicianTaxonomy code 2080A0000X
Legal business name
SHAKER PEDIATRICS PC
Practice address
10 Century Hill Drive
Latham, NY 12110
Phone
(518) 783-5563
Fax
(518) 785-5708
NPI assigned
Aug 2, 2006
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Henry M Neilley, MDNPI 1699880864
Title
First Vice President
Phone
(518) 783-5563

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric Adolescent Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2080A0000X Primary

Addresses

Primary practice location

10 Century Hill Drive
Latham, NY 12110

Mailing address

10 Century Hill Drive
Latham, NY 12110
Phone (518) 783-5563

Other identifiers 20

IdentifierTypeStateIssuer
01762674MedicaidNY
26210OtherMVP MARYLA WARSZAWA-AMB
000401340001OtherBS SHEELA GRANEY MD
01260746MedicaidNY
26208OtherMVP WILLIAM A PETERSEN MD
000401387001OtherBS WILLIAM A PETERSEN MD
10002804OtherCDPHP WM A PETERSEN MD
26207OtherMVP HENRY NEILLEY MD
000401569001OtherBS HENRY NEILLEY MD
10001463OtherCDPHP HENRY NEILLEY MD
10044836OtherCDPHP DAVID SHERWOOD MD
964787OtherMVP SHEELA GRANEY MD
00392741MedicaidNY
349679OtherMVP DAVID SHERWOOD MD
10002139OtherCDPHP MARYLA WARSZAWA-AMB
10021167OtherCDPHP SHEELA GRANEY MD
00962767MedicaidNY
01332856MedicaidNY
02094695MedicaidNY
1007OtherCDPHP GROUP

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
33D0161435Shaker Pediatrics10 Century Hill Drive, Suite 5, Latham, NY 12110ComplianceJun 9, 2026

National Provider Directory

National Provider Directory

Locations

10 Century Hill Dr
Latham, NY 12110
Phone (518) 783-5563

10 Century Hill Dr
Ste 5
Latham, NY 12110

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1154476800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1336156223",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10 CENTURY HILL DRIVE",
            "city": "LATHAM",
            "state": "NY",
            "postal_code": "12110",
            "telephone_number": "518-783-5563",
            "fax_number": "518-785-5708"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10 CENTURY HILL DRIVE",
            "city": "LATHAM",
            "state": "NY",
            "postal_code": "12110",
            "telephone_number": "518-783-5563",
            "fax_number": "518-785-5708"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHAKER PEDIATRICS PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-02",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "NEILLEY",
        "authorized_official_first_name": "HENRY",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "FIRST VICE PRESIDENT",
        "authorized_official_telephone_number": "518-783-5563",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "2080A0000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics, Adolescent Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "01762674",
            "state": "NY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MVP MARYLA WARSZAWA-AMB",
            "identifier": "26210",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BS SHEELA GRANEY MD",
            "identifier": "000401340001",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "01260746",
            "state": "NY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MVP WILLIAM A PETERSEN MD",
            "identifier": "26208",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BS WILLIAM A PETERSEN MD",
            "identifier": "000401387001",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CDPHP WM A PETERSEN MD",
            "identifier": "10002804",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MVP HENRY NEILLEY MD",
            "identifier": "26207",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BS HENRY NEILLEY MD",
            "identifier": "000401569001",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CDPHP HENRY NEILLEY MD",
            "identifier": "10001463",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CDPHP DAVID SHERWOOD MD",
            "identifier": "10044836",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MVP SHEELA GRANEY MD",
            "identifier": "964787",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00392741",
            "state": "NY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MVP DAVID SHERWOOD MD",
            "identifier": "349679",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CDPHP MARYLA WARSZAWA-AMB",
            "identifier": "10002139",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CDPHP SHEELA GRANEY MD",
            "identifier": "10021167",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00962767",
            "state": "NY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "01332856",
            "state": "NY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "02094695",
            "state": "NY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CDPHP GROUP",
            "identifier": "1007",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Latham, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.