Provider Demographics
NPI:1629439427
Name:PM PEDIATRICS OF STATEN ISLAND
Entity Type:Organization
Organization Name:PM PEDIATRICS OF STATEN ISLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, CREDENTIALING/ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:MARLENA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-207-7851
Mailing Address - Street 1:1 HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1220
Mailing Address - Country:US
Mailing Address - Phone:516-869-0650
Mailing Address - Fax:516-869-0655
Practice Address - Street 1:2407 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3906
Practice Address - Country:US
Practice Address - Phone:718-698-5437
Practice Address - Fax:718-698-5444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208000000X
261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty