Provider Demographics
NPI:1851828107
Name:PM PEDIATRICS OF NEW ENGLAND LLC
Entity type:Organization
Organization Name:PM PEDIATRICS OF NEW ENGLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER CREDENTIALING/ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-207-7936
Mailing Address - Street 1:1 HOLLOW LANE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LAKE SUCCESS
Mailing Address - State:NY
Mailing Address - Zip Code:11042
Mailing Address - Country:US
Mailing Address - Phone:516-869-0650
Mailing Address - Fax:516-673-9408
Practice Address - Street 1:719 PROVIDENCE HIGHWAY
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:NY
Practice Address - Zip Code:02026
Practice Address - Country:US
Practice Address - Phone:781-461-6767
Practice Address - Fax:781-461-6774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-17
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QU0200X
MA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty