Healthcare Provider Details

I. General information

NPI: 1528485398
Provider Name (Legal Business Name): PEDIATRICS OF RICHMOMD COUNTY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2014
Last Update Date: 03/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

491 HENDERSON AVE
STATEN ISLAND NY
10310-1665
US

IV. Provider business mailing address

491 HENDERSON AVE
STATEN ISLAND NY
10310-1665
US

V. Phone/Fax

Practice location:
  • Phone: 718-816-0640
  • Fax: 718-816-6662
Mailing address:
  • Phone: 718-816-0640
  • Fax: 718-816-6662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number104893
License Number StateNY

VIII. Authorized Official

Name: DR. MARINA A CORPUS
Title or Position: PRESIDENT
Credential: MD
Phone: 718-816-0640