Provider Demographics
NPI:1720121635
Name:PEDIATRIC NEUROLOGY, INC.
Entity Type:Organization
Organization Name:PEDIATRIC NEUROLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:YOUNES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-334-0424
Mailing Address - Street 1:2138 MENDON RD
Mailing Address - Street 2:UNIT 104
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-3834
Mailing Address - Country:US
Mailing Address - Phone:401-334-0424
Mailing Address - Fax:
Practice Address - Street 1:2138 MENDON RD
Practice Address - Street 2:UNIT 104
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-3834
Practice Address - Country:US
Practice Address - Phone:401-334-0424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI76912084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPN44005Medicaid