Healthcare Provider Details

I. General information

NPI: 1003883653
Provider Name (Legal Business Name): PEDIATRIC CARDIOLOGY OF LI PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 03/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PORT WASHINGTON BLVD SUITE 108
ROSLYN NY
11576-1347
US

IV. Provider business mailing address

100 PORT WASHINGTON BLVD SUITE 108
ROSLYN NY
11576-1347
US

V. Phone/Fax

Practice location:
  • Phone: 516-365-3340
  • Fax: 516-365-5512
Mailing address:
  • Phone: 516-365-3340
  • Fax: 516-365-5512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number175239
License Number StateNY

VIII. Authorized Official

Name: AMBROSE M. VALLONE
Title or Position: PARTNER
Credential: M.D.
Phone: 516-365-3340