Provider Demographics
NPI:1528409026
Name:PM PEDIATRICS OF BAYSIDE
Entity Type:Organization
Organization Name:PM PEDIATRICS OF BAYSIDE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. DIRECTOR, CRED & ENROLLMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARLENA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPMSMS
Authorized Official - Phone:516-207-7851
Mailing Address - Street 1:ONE HOLLOW LANE
Mailing Address - Street 2:
Mailing Address - City:LAKE SUCCESS
Mailing Address - State:NY
Mailing Address - Zip Code:11042
Mailing Address - Country:US
Mailing Address - Phone:516-869-0650
Mailing Address - Fax:516-869-0655
Practice Address - Street 1:240 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5762
Practice Address - Country:US
Practice Address - Phone:516-677-5437
Practice Address - Fax:516-673-9408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-12
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty