Provider Demographics
NPI:1073538658
Name:PEDI DOC, P.A.
Entity Type:Organization
Organization Name:PEDI DOC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BERNIER
Authorized Official - Middle Name:
Authorized Official - Last Name:LAUREDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-371-1600
Mailing Address - Street 1:22 BALL ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-3521
Mailing Address - Country:US
Mailing Address - Phone:973-371-1600
Mailing Address - Fax:
Practice Address - Street 1:205 SMITH ST
Practice Address - Street 2:SUITE D
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-4323
Practice Address - Country:US
Practice Address - Phone:732-697-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSEX PEDI DOC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-13
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05388700305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0677701Medicare ID - Type Unspecified