Provider Demographics
NPI:1437686219
Name:PEMBERTON M.D P.C
Entity Type:Organization
Organization Name:PEMBERTON M.D P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PEMBERTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-844-3188
Mailing Address - Street 1:500 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-2944
Mailing Address - Country:US
Mailing Address - Phone:973-844-3188
Mailing Address - Fax:
Practice Address - Street 1:500 ORANGE ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-2944
Practice Address - Country:US
Practice Address - Phone:973-844-3188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0198323Medicaid
NJ0198323Medicaid