Healthcare Provider Details

I. General information

NPI: 1013063080
Provider Name (Legal Business Name): PELHAM PODIATRY GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 05/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 MORRIS PARK AVENUE
BRONX NY
10462
US

IV. Provider business mailing address

1015 MORRIS PARK AVENUE
BRONX NY
10462
US

V. Phone/Fax

Practice location:
  • Phone: 718-409-2121
  • Fax: 718-863-3666
Mailing address:
  • Phone: 718-409-2121
  • Fax: 718-863-3666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberN005627
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberN005627
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN005627
License Number StateNY

VIII. Authorized Official

Name: DR. CRAIG PRESTON HERMAN
Title or Position: OWNER
Credential: DPM
Phone: 718-409-2121