Provider Demographics
NPI:1962902650
Name:PM PEDIATRICS OF VIRGINIA
Entity type:Organization
Organization Name:PM PEDIATRICS OF VIRGINIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER CREDENTIALING/ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-207-7936
Mailing Address - Street 1:1 HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1220
Mailing Address - Country:US
Mailing Address - Phone:516-869-0650
Mailing Address - Fax:516-869-0655
Practice Address - Street 1:6358 SPRINGFIELD PLZ
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-3431
Practice Address - Country:US
Practice Address - Phone:703-644-5437
Practice Address - Fax:703-644-6767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-19
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA208000000X
261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty