Basic Information
| Provider Information | |||||||||
| NPI: | 1164590204 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PICKERT MEDICAL GROUP, P.C. | ||||||||
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| OtherOrganizationName: | CLASS, IDLER AND ASSOCIATES, P.C. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1305 WALT WHITMAN RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117474300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162084250 | ||||||||
| FaxNumber: | 7042485537 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 E LIBERTY ST | ||||||||
| Address2: | SUITE 555 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895012097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753481900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 03/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | HOBERG | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7747504110 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 03/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 100505684 | 05 | NV | MEDICAID |