Healthcare Provider Details

I. General information

NPI: 1205804770
Provider Name (Legal Business Name): TLC PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WEBSTER AVE SUITE 302
POUGHKEEPSIE NY
12601-1361
US

IV. Provider business mailing address

1 WEBSTER AVE SUITE 302
POUGHKEEPSIE NY
12601-1361
US

V. Phone/Fax

Practice location:
  • Phone: 845-483-5852
  • Fax: 845-483-5413
Mailing address:
  • Phone: 845-483-5852
  • Fax: 845-483-5413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number1550961
License Number StateNY

VII. Legacy identifiers

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

VIII. Authorized Official

Name: PARVANEH BOROJENI
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 845-483-5852