Provider Demographics
NPI:1427416304
Name:BAYONNE PEDIATRIC PRACTICE
Entity Type:Organization
Organization Name:BAYONNE PEDIATRIC PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHALINI
Authorized Official - Middle Name:NAGARAJAN
Authorized Official - Last Name:RAGHU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-823-4141
Mailing Address - Street 1:21 TAMARACK RD
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-3630
Mailing Address - Country:US
Mailing Address - Phone:201-823-4141
Mailing Address - Fax:201-823-1141
Practice Address - Street 1:765 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002
Practice Address - Country:US
Practice Address - Phone:201-823-4141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-05
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08140300208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty