Healthcare Provider Details

I. General information

NPI: 1760845424
Provider Name (Legal Business Name): SV PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 03/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 E WOODSIDE AVE
PATCHOGUE NY
11772-1423
US

IV. Provider business mailing address

155 E WOODSIDE AVE
PATCHOGUE NY
11772-1423
US

V. Phone/Fax

Practice location:
  • Phone: 631-758-6565
  • Fax: 631-758-6568
Mailing address:
  • Phone: 631-758-6565
  • Fax: 631-758-6568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF382507
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. MICHELE DAVIEDS
Title or Position: OFFICE MANAGER
Credential:
Phone: 631-758-6565