Healthcare Provider Details

I. General information

NPI: 1770993644
Provider Name (Legal Business Name): STATEN ISLAND PEDIATRIC CARDIOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2014
Last Update Date: 05/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 VICTORY BLVD 302
STATEN ISLAND NY
10314-6611
US

IV. Provider business mailing address

2550 VICTORY BLVD 302
STATEN ISLAND NY
10314-6611
US

V. Phone/Fax

Practice location:
  • Phone: 718-983-1496
  • Fax:
Mailing address:
  • Phone: 718-983-1496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JARED C LACORTE
Title or Position: OWNER
Credential: MD
Phone: 718-983-1496