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General NPI Number Information
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NPI Number | 1104960962
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL EVALUATION MEDICAL GROUP
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Dates
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Enumeration Date | 02/16/2007
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Last Update Date | 11/10/2011
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Provider Practice Location Address
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Address Line | 380 S BROADWAY
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City | HICKSVILLE
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State | NY
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Zip | 11801-5033
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Country | US
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Telephone | 516-935-4378
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Fax | 516-931-3117
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Provider Business Mailing Address
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Address Line | 380 S BROADWAY
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City | HICKSVILLE
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State | NY
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Zip | 11801-5033
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Country | US
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Telephone | 516-935-4378
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Fax | 516-931-3117
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. JAMES MICHAEL SHEEHY
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Credential |
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Telephone | 516-935-4378
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | 147150
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License Number State | NY
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