Provider Demographics
NPI:1497709661
Name:PEDIATRIC INTENSIVE CARE ASSOCIATES
Entity Type:Organization
Organization Name:PEDIATRIC INTENSIVE CARE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ CHAIRMAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:TEDESCHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-782-3300
Mailing Address - Street 1:402 LIPPINCOTT DR
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4112
Mailing Address - Country:US
Mailing Address - Phone:856-782-3300
Mailing Address - Fax:856-504-8029
Practice Address - Street 1:101 CARNIE BLVD
Practice Address - Street 2:PICU
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-1548
Practice Address - Country:US
Practice Address - Phone:856-782-3300
Practice Address - Fax:856-504-8029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ041581Medicaid