Provider Demographics
NPI:1457446585
Name:PEDIATRIC MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:PEDIATRIC MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:REYES
Authorized Official - Last Name:JACANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-522-1313
Mailing Address - Street 1:1712 LILIHA STREET
Mailing Address - Street 2:SUITE304
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-3114
Mailing Address - Country:US
Mailing Address - Phone:808-522-1313
Mailing Address - Fax:808-522-1309
Practice Address - Street 1:1712 LILIHA STREET
Practice Address - Street 2:SUITE304
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-3114
Practice Address - Country:US
Practice Address - Phone:808-522-1313
Practice Address - Fax:808-522-1309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1854305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization