Provider Demographics
NPI:1043314453
Name:PEDIATRIC HEALTH, PA
Entity Type:Organization
Organization Name:PEDIATRIC HEALTH, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:LOPEZ
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-780-3333
Mailing Address - Street 1:69 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2114
Mailing Address - Country:US
Mailing Address - Phone:732-409-3633
Mailing Address - Fax:732-409-7133
Practice Address - Street 1:470 STILLWELLS CORNER RD
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2969
Practice Address - Country:US
Practice Address - Phone:732-780-3333
Practice Address - Fax:732-780-6968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3196305Medicaid