Provider Demographics
NPI:1508971292
Name:IRONBOUND PEDIATRICS PC
Entity Type:Organization
Organization Name:IRONBOUND PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NORMITA
Authorized Official - Middle Name:BELTRAN
Authorized Official - Last Name:VICENTE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:973-466-0300
Mailing Address - Street 1:PO BOX 254
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-0254
Mailing Address - Country:US
Mailing Address - Phone:973-466-0300
Mailing Address - Fax:973-466-1117
Practice Address - Street 1:155 JEFFERSON ST
Practice Address - Street 2:LL STE 3
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-1706
Practice Address - Country:US
Practice Address - Phone:973-466-0300
Practice Address - Fax:973-466-1777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ50441OtherAETNA
NJ0050432Medicaid
NJ2353177001OtherAMERIHEALTH