Provider Demographics
NPI:1528485398
Name:PEDIATRICS OF RICHMOMD COUNTY PLLC
Entity type:Organization
Organization Name:PEDIATRICS OF RICHMOMD COUNTY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CORPUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-816-0640
Mailing Address - Street 1:491 HENDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-1665
Mailing Address - Country:US
Mailing Address - Phone:718-816-0640
Mailing Address - Fax:718-816-6662
Practice Address - Street 1:491 HENDERSON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-1665
Practice Address - Country:US
Practice Address - Phone:718-816-0640
Practice Address - Fax:718-816-6662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-18
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104893208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00182485Medicaid