Healthcare Provider Details

I. General information

NPI: 1720826647
Provider Name (Legal Business Name): IMAGINE PEDIATRICS MEDICAL OF NEW YORK, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 OLD HICKORY BLVD STE 140
BRENTWOOD TN
37027-4556
US

IV. Provider business mailing address

750 OLD HICKORY BLVD STE 140
BRENTWOOD TN
37027-4556
US

V. Phone/Fax

Practice location:
  • Phone: 833-208-7770
  • Fax:
Mailing address:
  • Phone: 833-208-7770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateNULL
# 10
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: PATRICIA MELO HAYES
Title or Position: PRESIDENT
Credential: MD
Phone: 832-746-5683