Provider Demographics
NPI:1598788440
Name:PEDIATRIC GROUP OF HONOLULU, LLP
Entity Type:Organization
Organization Name:PEDIATRIC GROUP OF HONOLULU, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:T
Authorized Official - Last Name:HARTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-955-7845
Mailing Address - Street 1:1319 PUNAHOU ST
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96826-1001
Mailing Address - Country:US
Mailing Address - Phone:808-955-7845
Mailing Address - Fax:808-946-3071
Practice Address - Street 1:1319 PUNAHOU ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96826-1001
Practice Address - Country:US
Practice Address - Phone:808-955-7845
Practice Address - Fax:808-946-3071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI250788Medicaid