Provider Demographics
NPI:1619508900
Name:TOTAL CARE PEDIATRIC, PLLC
Entity Type:Organization
Organization Name:TOTAL CARE PEDIATRIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHAK
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-323-2300
Mailing Address - Street 1:4265 KISSENA BLVD
Mailing Address - Street 2:SUITE LL4
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-3273
Mailing Address - Country:US
Mailing Address - Phone:718-353-2300
Mailing Address - Fax:718-353-2454
Practice Address - Street 1:4265 KISSENA BLVD
Practice Address - Street 2:SUITE LL4
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3273
Practice Address - Country:US
Practice Address - Phone:718-353-2300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-27
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01755559Medicaid