Provider Demographics
NPI:1003883653
Name:PEDIATRIC CARDIOLOGY OF LI PC
Entity Type:Organization
Organization Name:PEDIATRIC CARDIOLOGY OF LI PC
Other - Org Name:PEDIATRIC CARDIOLOGY OF LI
Other - Org Type:Other Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:AMBROSE
Authorized Official - Middle Name:M
Authorized Official - Last Name:VALLONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-365-3340
Mailing Address - Street 1:100 PORT WASHINGTON BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-1347
Mailing Address - Country:US
Mailing Address - Phone:516-365-3340
Mailing Address - Fax:516-365-5512
Practice Address - Street 1:100 PORT WASHINGTON BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1347
Practice Address - Country:US
Practice Address - Phone:516-365-3340
Practice Address - Fax:516-365-5512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-02
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1752392080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY175239OtherLICENSE
NYC22899Medicare UPIN