Provider Demographics
NPI:1053461855
Name:PEDIATRIC AND ADOLESCENT MEDICINE
Entity Type:Organization
Organization Name:PEDIATRIC AND ADOLESCENT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MNG
Authorized Official - Prefix:MS
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:KINGSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-229-4540
Mailing Address - Street 1:223 MONMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:WEST LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07764-1029
Mailing Address - Country:US
Mailing Address - Phone:732-229-4540
Mailing Address - Fax:732-229-8689
Practice Address - Street 1:223 MONMOUTH RD
Practice Address - Street 2:
Practice Address - City:WEST LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07764-1029
Practice Address - Country:US
Practice Address - Phone:732-229-4540
Practice Address - Fax:732-229-8689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA373982080A0000X
NJMA0404002080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2003201Medicaid
NJ0238201Medicaid
NJ0238201Medicaid
NJD19873Medicare UPIN