Provider Demographics
NPI:1497797864
Name:RIVENDELL PEDIATRIC AND ADOLSCENT MEDICINE, PC
Entity Type:Organization
Organization Name:RIVENDELL PEDIATRIC AND ADOLSCENT MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HIRSCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-424-0340
Mailing Address - Street 1:25 HOMESTEAD DR
Mailing Address - Street 2:STE H
Mailing Address - City:COLUMBUS
Mailing Address - State:NJ
Mailing Address - Zip Code:08022-1005
Mailing Address - Country:US
Mailing Address - Phone:609-424-0340
Mailing Address - Fax:609-298-7452
Practice Address - Street 1:25 HOMESTEAD DR
Practice Address - Street 2:STE H
Practice Address - City:COLUMBUS
Practice Address - State:NJ
Practice Address - Zip Code:08022-1005
Practice Address - Country:US
Practice Address - Phone:609-424-0340
Practice Address - Fax:609-298-7452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04122800208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty