Provider Demographics
NPI:1104031939
Name:ELIZABETH PEDIATRIC GROUP, LLC
Entity Type:Organization
Organization Name:ELIZABETH PEDIATRIC GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-354-9500
Mailing Address - Street 1:701 NEWARK AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-3550
Mailing Address - Country:US
Mailing Address - Phone:908-354-9500
Mailing Address - Fax:908-354-9077
Practice Address - Street 1:701 NEWARK AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-3550
Practice Address - Country:US
Practice Address - Phone:908-354-9500
Practice Address - Fax:908-354-9077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04177300208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty