Healthcare Provider Details

I. General information

NPI: 1245583137
Provider Name (Legal Business Name): ISLAND PEDIATRICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 10/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 SLOSSON AVE
STATEN ISLAND NY
10314-2517
US

IV. Provider business mailing address

125 SLOSSON AVE
STATEN ISLAND NY
10314-2517
US

V. Phone/Fax

Practice location:
  • Phone: 718-390-0400
  • Fax: 718-390-0566
Mailing address:
  • Phone: 718-390-0400
  • Fax: 718-390-0566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number168902
License Number StateNY

VIII. Authorized Official

Name: DR. BRIAN ROBERT MCMAHON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 719-390-0400