Provider Demographics
NPI:1215179312
Name:PEDIARIC CENTER 2000 INC
Entity Type:Organization
Organization Name:PEDIARIC CENTER 2000 INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:RUBEN
Authorized Official - Last Name:ORTEGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-484-5401
Mailing Address - Street 1:1079 PLEASANT VALLEY WAY
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1418
Mailing Address - Country:US
Mailing Address - Phone:973-485-5401
Mailing Address - Fax:973-485-1536
Practice Address - Street 1:571 N 6TH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-2501
Practice Address - Country:US
Practice Address - Phone:973-485-5401
Practice Address - Fax:973-485-1536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA060606002080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6164102Medicaid