Healthcare Provider Details

I. General information

NPI: 1639478340
Provider Name (Legal Business Name): BAYSIDE PEDIATRIC CARE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 03/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22116 UNION TPKE
BAYSIDE NY
11364-3641
US

IV. Provider business mailing address

22116 UNION TPKE
BAYSIDE NY
11364-3641
US

V. Phone/Fax

Practice location:
  • Phone: 718-465-5888
  • Fax: 718-465-5889
Mailing address:
  • Phone: 718-465-5888
  • Fax: 718-465-5889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number240002
License Number StateNY

VIII. Authorized Official

Name: LI-MIN YANG
Title or Position: OFFICE MANAGER
Credential: M.D.
Phone: 718-465-5888