Provider Demographics
NPI:1144947797
Name:PM KIDS PLUS
Entity type:Organization
Organization Name:PM KIDS PLUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALI
Authorized Official - Middle Name:
Authorized Official - Last Name:GAUVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-585-7128
Mailing Address - Street 1:603 POST OFFICE RD STE 106
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-1914
Mailing Address - Country:US
Mailing Address - Phone:240-585-7128
Mailing Address - Fax:240-607-6749
Practice Address - Street 1:603 POST OFFICE RD STE 106
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-1914
Practice Address - Country:US
Practice Address - Phone:240-585-7128
Practice Address - Fax:240-607-6749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-25
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD961018900Medicaid