Provider Demographics
NPI:1518258359
Name:ESSEX PEDI DOCS LLC
Entity Type:Organization
Organization Name:ESSEX PEDI DOCS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNIER
Authorized Official - Middle Name:
Authorized Official - Last Name:LAUREDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-371-1600
Mailing Address - Street 1:22 BALL ST
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-3521
Mailing Address - Country:US
Mailing Address - Phone:973-371-1600
Mailing Address - Fax:973-372-7677
Practice Address - Street 1:22 BALL ST
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3521
Practice Address - Country:US
Practice Address - Phone:973-371-1600
Practice Address - Fax:973-372-7677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA53887208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0677701Medicaid