Provider Demographics
NPI:1245583137
Name:ISLAND PEDIATRICS, P.C.
Entity Type:Organization
Organization Name:ISLAND PEDIATRICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MCMAHON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-390-0400
Mailing Address - Street 1:125 SLOSSON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-2517
Mailing Address - Country:US
Mailing Address - Phone:718-390-0400
Mailing Address - Fax:718-390-0566
Practice Address - Street 1:125 SLOSSON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-2517
Practice Address - Country:US
Practice Address - Phone:718-390-0400
Practice Address - Fax:718-390-0566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168902208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01848993Medicaid