Provider Demographics
NPI:1194842674
Name:PEDIATRIC PROFESSIONALS, INC.
Entity Type:Organization
Organization Name:PEDIATRIC PROFESSIONALS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:808-593-9944
Mailing Address - Street 1:1350 S KING ST STE 300
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-2066
Mailing Address - Country:US
Mailing Address - Phone:808-593-9944
Mailing Address - Fax:808-593-0565
Practice Address - Street 1:1350 S KING ST STE 300
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-2066
Practice Address - Country:US
Practice Address - Phone:808-593-9944
Practice Address - Fax:808-593-0565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD4255174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI02534679801OtherUHA
HI192509OtherHMAI
HI04481OtherHMSA 2
HI00519101OtherDSS
HIMD4255-01OtherQHCP
HIJ4489OtherHMSA
HI00519101Medicaid
HI0000004481OtherQHMS 2
HIC98518Medicare UPIN
HI00519101Medicaid