Provider Demographics
NPI:1861823197
Name:PM PEDIATRICS OF BAYSIDE PLLC
Entity Type:Organization
Organization Name:PM PEDIATRICS OF BAYSIDE 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:
Authorized Official - Phone:516-207-7851
Mailing Address - Street 1:ONE 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:
Practice Address - Street 1:19 SPRING VALLEY MARKET PLACE
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10977
Practice Address - Country:US
Practice Address - Phone:845-371-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-12
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency MedicineGroup - Single Specialty