Provider Demographics
NPI:1003854092
Name:BHATTACHARYYA, NISHITH (MD)
Entity Type:Individual
Prefix:
First Name:NISHITH
Middle Name:
Last Name:BHATTACHARYYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 785361
Mailing Address - Street 2:PEDIATRIC SURGERY GROUP
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178
Mailing Address - Country:US
Mailing Address - Phone:888-287-3652
Mailing Address - Fax:973-549-6079
Practice Address - Street 1:2130 MILLBURN AVENUE
Practice Address - Street 2:PEDIATRIC SURGERY GROUP
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040
Practice Address - Country:US
Practice Address - Phone:888-287-3652
Practice Address - Fax:973-549-6079
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA06698602086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7558406Medicaid
NJ7558406Medicaid