MEDICARE: PM PEDIATRICS OF CONNECTICUT

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
2	261QU0200X	Urgent Care Clinic/Center

General Provider Information

NPI Number	:	1386158467
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PM PEDIATRICS OF CONNECTICUT

Provider Business Mailing Address
First Line	:	1 HOLLOW LN STE 301
Second Line	:
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11042-1215
Country	:	US
Telephone Number	:	516-869-0650
Fax Number	:	516-673-9408

Provider Business Practice Location Address
First Line	:	1459 NEW BRITAIN AVE
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06110-1659
Country	:	US
Telephone Number	:	860-232-5437
Fax Number	:	860-232-2110

Authorized Official
Title or Position	:	MANAGER CREDENTIALING/ENROLLMENT
Name	:	DANIELLE MARIE LOPEZ
Credential	:
Telephone Number	:	516-207-7936

Provider Enumeration Date	:	11/28/2017
Last Update Date	:	01/21/2025

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