MEDICARE: PEDIATRIC CARDIOLOGY OF LI PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080P0202X	Pediatric Cardiology Physician	175239	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	175239	OTHER	NY	LICENSE

General Provider Information

NPI Number	:	1003883653
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC CARDIOLOGY OF LI PC

Provider Business Mailing Address
First Line	:	100 PORT WASHINGTON BLVD
Second Line	:	SUITE 108
City	:	ROSLYN
State	:	NY
Zip	:	11576-1347
Country	:	US
Telephone Number	:	516-365-3340
Fax Number	:	516-365-5512

Provider Business Practice Location Address
First Line	:	100 PORT WASHINGTON BLVD
Second Line	:	SUITE 108
City	:	ROSLYN
State	:	NY
Zip	:	11576-1347
Country	:	US
Telephone Number	:	516-365-3340
Fax Number	:	516-365-5512

Authorized Official
Title or Position	:	PARTNER
Name	:	AMBROSE M. VALLONE
Credential	:	M.D.
Telephone Number	:	516-365-3340

Provider Enumeration Date	:	03/02/2006
Last Update Date	:	03/25/2013

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