Healthcare Provider Details

I. General information

NPI: 1114907730
Provider Name (Legal Business Name): PANAGIOTIS GEORGE PSALIDAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 ENGLE STREET
ENGLEWOOD NJ
07631
US

IV. Provider business mailing address

227 W 27TH ST RM A402
NEW YORK NY
10001-5992
US

V. Phone/Fax

Practice location:
  • Phone: 201-569-9005
  • Fax: 201-569-9080
Mailing address:
  • Phone: 212-217-4190
  • Fax: 212-217-4191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA07276300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number204950
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA07276300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: