Healthcare Provider Details

I. General information

NPI: 1356190110
Provider Name (Legal Business Name): PM PEDIATRICS MANAGEMENT GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOLLOW LN STE 301
NEW HYDE PARK NY
11042-1215
US

IV. Provider business mailing address

1 HOLLOW LN STE 301
NEW HYDE PARK NY
11042-1215
US

V. Phone/Fax

Practice location:
  • Phone: 516-869-0650
  • Fax: 516-869-0655
Mailing address:
  • Phone: 516-869-0650
  • Fax: 516-869-0655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. MARLENA SIMPSON
Title or Position: SR DIR, CREDENTIALS & ENROLLMENT
Credential: CPMSM
Phone: 516-207-7851