Provider Demographics
NPI:1407959570
Name:GARDEN STATE PEDIACTRICS LLC
Entity Type:Organization
Organization Name:GARDEN STATE PEDIACTRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMI
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:SCANLON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:201-263-1477
Mailing Address - Street 1:217 OLD HOOK RD
Mailing Address - Street 2:SUITE 3C GARDEN STATE PEDIATRICS
Mailing Address - City:WESTWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07675
Mailing Address - Country:US
Mailing Address - Phone:201-263-1477
Mailing Address - Fax:201-263-0048
Practice Address - Street 1:217 OLD HOOK RD
Practice Address - Street 2:SUITE 3C GARDEN STATE PEDIATRICS LLC
Practice Address - City:WESTWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07675
Practice Address - Country:US
Practice Address - Phone:201-263-1477
Practice Address - Fax:201-263-0048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07383700208000000X
NJ25MA06742400208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty