Healthcare Provider Details

I. General information

NPI: 1073612768
Provider Name (Legal Business Name): PEDIATRIC AND ADOLESCENT MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 W END AVE
NEW YORK NY
10024-6107
US

IV. Provider business mailing address

390 W END AVE
NEW YORK NY
10024-6107
US

V. Phone/Fax

Practice location:
  • Phone: 212-787-1444
  • Fax: 212-799-8620
Mailing address:
  • Phone: 212-787-1444
  • Fax: 212-799-8620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MAX KAHN
Title or Position: SENIOR PARTNER IN PRACTICE
Credential:
Phone: 212-787-1444