Provider Demographics
NPI:1710032453
Name:QUEENS PEDIATRIC CARDIOLOGY, PC
Entity Type:Organization
Organization Name:QUEENS PEDIATRIC CARDIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAMODAR
Authorized Official - Middle Name:
Authorized Official - Last Name:THAMBIREDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-565-0700
Mailing Address - Street 1:8708 JUSTICE AVE
Mailing Address - Street 2:SUITE CF
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4590
Mailing Address - Country:US
Mailing Address - Phone:718-565-0700
Mailing Address - Fax:
Practice Address - Street 1:8708 JUSTICE AVE
Practice Address - Street 2:SUITE CF
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-4590
Practice Address - Country:US
Practice Address - Phone:718-565-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2344772080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02624133Medicaid