1194842674 NPI number — PEDIATRIC PROFESSIONALS, INC.

Table of content: (NPI 1194842674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194842674 NPI number — PEDIATRIC PROFESSIONALS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC PROFESSIONALS, INC.
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:
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:
1194842674
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1350 S KING ST STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96814-2066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-593-9944
Provider Business Mailing Address Fax Number:
808-593-0565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1350 S KING ST STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96814-2066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-593-9944
Provider Business Practice Location Address Fax Number:
808-593-0565
Provider Enumeration Date:
03/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MATTHEWS
Authorized Official First Name:
WALLACE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
808-593-9944

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MD4255 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02534679801 . This is a "UHA" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 192509 . This is a "HMAI" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 04481 . This is a "HMSA 2" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 00519101 . This is a "DSS" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: MD4255-01 . This is a "QHCP" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: J4489 . This is a "HMSA" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 00519101 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000004481 . This is a "QHMS 2" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".




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