1396006805 NPI number — THE CHILDREN'S MEDICAL GROUP PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396006805 NPI number — THE CHILDREN'S MEDICAL GROUP PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE CHILDREN'S MEDICAL GROUP PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396006805
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 MANCHESTER RD STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POUGHKEEPSIE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12603-2587
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-452-1700
Provider Business Mailing Address Fax Number:
845-452-1752

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 HOOK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RHINEBECK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12572-1145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-452-1700
Provider Business Practice Location Address Fax Number:
845-452-1752
Provider Enumeration Date:
05/31/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MAYHEW
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
845-452-1700

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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