Provider Demographics
NPI:1740492347
Name:NATIONAL PEDIATRIC MD PC
Entity type:Organization
Organization Name:NATIONAL PEDIATRIC MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:BIENVENIDO
Authorized Official - Last Name:FLORIMON DE LA ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-898-5200
Mailing Address - Street 1:10211 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-2331
Mailing Address - Country:US
Mailing Address - Phone:718-898-5200
Mailing Address - Fax:718-898-1251
Practice Address - Street 1:10211 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2331
Practice Address - Country:US
Practice Address - Phone:718-898-5200
Practice Address - Fax:718-898-1251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189653261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01455449Medicaid