Healthcare Provider Details

I. General information

NPI: 1174610091
Provider Name (Legal Business Name): SPRINGFIELD PEDIATRIC P. C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23520 147TH AVE STE 4
ROSEDALE NY
11422-3293
US

IV. Provider business mailing address

23520 147TH AVENUE SUITE 4
ROSEDALE NY
11422
US

V. Phone/Fax

Practice location:
  • Phone: 718-712-2200
  • Fax: 718-712-5666
Mailing address:
  • Phone: 718-712-2200
  • Fax: 718-712-5666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number142782
License Number StateNY

VIII. Authorized Official

Name: HABIB NAZARIAN
Title or Position: OFFICER
Credential: M.D.
Phone: 718-712-2200