MEDICARE: KIDS PRIDE PEDIATRICS, 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	208000000X	Pediatrics Physician	235529	NY

General Provider Information

NPI Number	:	1902298789
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS PRIDE PEDIATRICS, PC

Provider Business Mailing Address
First Line	:	20801 HILLSIDE AVE
Second Line	:	1ST FLOOR
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11427-1711
Country	:	US
Telephone Number	:	718-479-7337
Fax Number	:	718-479-2031

Provider Business Practice Location Address
First Line	:	20801 HILLSIDE AVE
Second Line	:	1ST FLOOR
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11427-1711
Country	:	US
Telephone Number	:	718-479-7337
Fax Number	:	718-479-2031

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	SARABJIT SINGH PHOKELA
Credential	:	MD
Telephone Number	:	718-479-7337

Provider Enumeration Date	:	03/03/2015
Last Update Date	:	03/03/2015

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