Provider Demographics
NPI:1285673723
Name:GENESIS PEDIATRICS ASSOCIATES, LLC
Entity Type:Organization
Organization Name:GENESIS PEDIATRICS ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:DURELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-848-2332
Mailing Address - Street 1:297 WESTWOOD DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WEST DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-3144
Mailing Address - Country:US
Mailing Address - Phone:856-848-2332
Mailing Address - Fax:856-848-5955
Practice Address - Street 1:297 WESTWOOD DR
Practice Address - Street 2:SUITE 101
Practice Address - City:WEST DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096-3144
Practice Address - Country:US
Practice Address - Phone:856-848-2332
Practice Address - Fax:856-848-5955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA044017208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty