Provider Demographics
NPI:1083765010
Name:PROVIDENCE PEDIATRIC MEDICAL DAYCARE, INC.
Entity Type:Organization
Organization Name:PROVIDENCE PEDIATRIC MEDICAL DAYCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LEEANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-753-7763
Mailing Address - Street 1:411 COMMERCE LN
Mailing Address - Street 2:
Mailing Address - City:WEST BERLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08091-9254
Mailing Address - Country:US
Mailing Address - Phone:856-753-7763
Mailing Address - Fax:856-753-7714
Practice Address - Street 1:1000 ATLANTIC AVE
Practice Address - Street 2:CAMDEN D, 2ND FLOOR
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08104-1132
Practice Address - Country:US
Practice Address - Phone:856-338-0900
Practice Address - Fax:856-338-0029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ158222261QM3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8839786Medicare UPIN