Healthcare Provider Details

I. General information

NPI: 1346500071
Provider Name (Legal Business Name): THE CHILDREN'S MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2012
Last Update Date: 10/21/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 GIDNEY AVE
NEWBURGH NY
12550-3116
US

IV. Provider business mailing address

301 MANCHESTER RD STE 105
POUGHKEEPSIE NY
12603-2587
US

V. Phone/Fax

Practice location:
  • Phone: 845-452-1700
  • Fax: 845-452-1752
Mailing address:
  • Phone: 845-452-1700
  • Fax: 845-452-1752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY MAYHEW
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 845-452-1700