CMS-1500 Box 24J / 33a • NPI
1083691539
Type 2 Organization (Box 32a/33a)
HIPAA NUCC Taxonomy • CMS Code
174400000X
Board-Certified Pediatrician (Infant, Child & Adolescent Medicine)
Box 32 Service Location & ZIP+4
3400 BAINBRIDGE AVE, GREENE MEDICAL ARTS PAVILION 3RD FLOOR, BRONX, NY, 10467-2404
✓ 9-Digit EDI 837 ZIP+4 (10467-2404)
✓ HHS OIG LEIE Sanction Screening — VERIFIED CLEAR:
NPI
1083691539 (55 SANDALWOOD ENTERPRISES INC) has 0 active federal exclusions across all 84,224 HHS OIG LEIE sanction records (Database Verified: 2026-11-11).
CMS Medicare Order & Referring PECOS Eligibility
Official CMS NPPES Credential & Practice Profile
| 10-Digit NPI Number | 1083691539 (NPI-2 Organization / Facility) |
|---|---|
| Provider / Legal Name | 55 SANDALWOOD ENTERPRISES INC |
| Plain-English Specialty | Board-Certified Pediatrician (Infant, Child & Adolescent Medicine) NUCC Code: 174400000X (Specialist) |
| Certifying / Licensing Body | American Board of Pediatrics (ABP) |
| Practice Location Address | 3400 BAINBRIDGE AVE, GREENE MEDICAL ARTS PAVILION 3RD FLOOR, BRONX, NY, 10467-2404 |
| Practice Telephone / Fax | Tel: (718) 920-4333 | Fax: (631) 447-7939 |
| Administrative Mailing Address | 20 MEDFORD AVE, PATCHOGUE, NY, 11772-1220 |
| Enumeration & Last Sync | Enumerated: 2005-12-27 | CMS Record Updated: 2020-08-22 |
| Authorized Official | PHYLLIS ZENKER (GENERAL MANAGER) |
Clinic Location, Accessibility & Directions
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Plain-English Taxonomy & CMS Crosswalk (174400000X)
What Does Taxonomy Code 174400000X Mean?
In the HIPAA National Uniform Claim Committee (NUCC) classification, code 174400000X translates to:
"Board-Certified Pediatrician (Infant, Child & Adolescent Medicine)"
Specialty Clinical Procedures & Therapeutic Classes
Standard Scope of Care (55 SANDALWOOD ENTERPRISES INC)
Typical CPT / Diagnostic Procedures:- Comprehensive Well-Child Developmental & Growth Visits (CPT 99381–99394)
- Childhood Immunization Administration (Rotavirus, MMR, DTaP, HPV, PCV)
- Neonatal Bilirubin & Jaundice Transcutaneous/Serum Screening
- Rapid Streptococcal, RSV & Influenza Point-of-Care Diagnostics
- Pediatric Asthma Nebulization & Spirometry Evaluation
- Amoxicillin / Amoxicillin-Clavulanate (Pediatric Otitis Media & Sinusitis)
- WHO Low-Osmolarity Oral Rehydration Salts (ORS) & Zinc Sulfate
- Albuterol Sulfate Inhalers & Fluticasone Pediatric Inhalers
- Weight-Based Acetaminophen & Ibuprofen Antipyretic Suspensions
All Registered NUCC Taxonomies & State Licenses
| Taxonomy Code & Plain-English Description | State License & Primary Status |
|---|---|
174400000X — SpecialistPlain English: Board-Certified Pediatrician (Infant, Child & Adolescent Medicine) | State: NY | License: 15000010884 | Primary: Yes (Primary) |
Medical Billing, RCM & Hospital Credentialing Teams:
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