MEDICARE: PROFESSIONAL EVALUATION MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302F00000X	Exclusive Provider Organization	147150	NY

General Provider Information

NPI Number	:	1790818573
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL EVALUATION MEDICAL GROUP

Provider Business Mailing Address
First Line	:	380 S BROADWAY
Second Line	:
City	:	HICKSVILLE
State	:	NY
Zip	:	11801-5033
Country	:	US
Telephone Number	:	516-935-4378
Fax Number	:	516-931-3117

Provider Business Practice Location Address
First Line	:	229 W 36TH ST FL 10
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10018-8949
Country	:	US
Telephone Number	:	212-463-8605
Fax Number	:	212-463-8579

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. JAMES MICHAEL SHEEHY
Credential	:
Telephone Number	:	516-935-1730

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	11/10/2011

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