Provider Demographics
NPI:1184671380
Name:WILLIAMSTOWN PEDIATRIC PRACTICE,PA
Entity Type:Organization
Organization Name:WILLIAMSTOWN PEDIATRIC PRACTICE,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJESWARI
Authorized Official - Middle Name:
Authorized Official - Last Name:KANTHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-629-9000
Mailing Address - Street 1:925 S BLACK HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094-1900
Mailing Address - Country:US
Mailing Address - Phone:856-629-9000
Mailing Address - Fax:
Practice Address - Street 1:925 S BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08094-1900
Practice Address - Country:US
Practice Address - Phone:856-629-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05934000208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty