Provider Demographics
NPI:1376903211
Name:IRIS PEDIATRICS, LLC
Entity Type:Organization
Organization Name:IRIS PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:YELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:POTYLITSINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-862-0200
Mailing Address - Street 1:702 N BEERS ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-1520
Mailing Address - Country:US
Mailing Address - Phone:732-862-0200
Mailing Address - Fax:
Practice Address - Street 1:702 N BEERS ST
Practice Address - Street 2:SUITE 1
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-1520
Practice Address - Country:US
Practice Address - Phone:732-862-0200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08017300261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care