MEDICARE: ISLAND PEDIATRICS, P.C.

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	208000000X	Pediatrics Physician	168902	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245583137
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ISLAND PEDIATRICS, P.C.

Provider Business Mailing Address
First Line	:	125 SLOSSON AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-2517
Country	:	US
Telephone Number	:	718-390-0400
Fax Number	:	718-390-0566

Provider Business Practice Location Address
First Line	:	125 SLOSSON AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-2517
Country	:	US
Telephone Number	:	718-390-0400
Fax Number	:	718-390-0566

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRIAN ROBERT MCMAHON
Credential	:	M.D.
Telephone Number	:	719-390-0400

Provider Enumeration Date	:	10/17/2012
Last Update Date	:	10/17/2012

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Directions to “ISLAND PEDIATRICS, P.C. ” Practice Location

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