Provider Demographics
NPI:1790818573
Name:PROFESSIONAL EVALUATION MEDICAL GROUP
Entity Type:Organization
Organization Name:PROFESSIONAL EVALUATION MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SHEEHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-935-1730
Mailing Address - Street 1:380 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-5033
Mailing Address - Country:US
Mailing Address - Phone:516-935-4378
Mailing Address - Fax:516-931-3117
Practice Address - Street 1:229 W 36TH ST FL 10
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-8949
Practice Address - Country:US
Practice Address - Phone:212-463-8605
Practice Address - Fax:212-463-8579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY147150302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY340681Medicare UPIN
NY9X0231Medicare UPIN
NYW24631Medicare UPIN
NY61D481Medicare ID - Type Unspecified