Provider Demographics
NPI:1639430515
Name:PM PEDIATRICS OF LIVINGSTON, PLLC
Entity Type:Organization
Organization Name:PM PEDIATRICS OF LIVINGSTON, PLLC
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:CPMSM
Authorized Official - Phone:516-207-7851
Mailing Address - Street 1:1 HOLLOW LANE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
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 1:577 W MOUNT PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-1607
Practice Address - Country:US
Practice Address - Phone:516-869-0650
Practice Address - Fax:516-869-0655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ174400000X
261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty