Healthcare Provider Details

I. General information

NPI: 1457446585
Provider Name (Legal Business Name): PEDIATRIC MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 LILIHA STREET SUITE304
HONOLULU HI
96817-3114
US

IV. Provider business mailing address

1712 LILIHA STREET SUITE304
HONOLULU HI
96817-3114
US

V. Phone/Fax

Practice location:
  • Phone: 808-522-1313
  • Fax: 808-522-1309
Mailing address:
  • Phone: 808-522-1313
  • Fax: 808-522-1309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number1854
License Number StateHI

VIII. Authorized Official

Name: DR. AMELIA REYES JACANG
Title or Position: PEDIATRICIAN
Credential: M.D.
Phone: 808-522-1313