Provider Demographics
NPI:1962552802
Name:ST. NICHOLAS PEDIATRICS, PC
Entity type:Organization
Organization Name:ST. NICHOLAS PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:VALENCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-928-8188
Mailing Address - Street 1:3230 156TH ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-3326
Mailing Address - Country:US
Mailing Address - Phone:212-928-8188
Mailing Address - Fax:212-928-8040
Practice Address - Street 1:1559 SAINT NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-4261
Practice Address - Country:US
Practice Address - Phone:212-928-8188
Practice Address - Fax:212-929-8040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02219529Medicaid
NY=========OtherTAX ID