Provider Demographics
NPI:1629286000
Name:PRINCETON HEALTHCARE PROVIDER GROUP LLC
Entity Type:Organization
Organization Name:PRINCETON HEALTHCARE PROVIDER GROUP LLC
Other - Org Name:BRISTOL MYERS SQUIBB COMMUNITY HEALTH CLINIC-PEDIATRIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VICE PRESIDENT, CHIEF FINANCIAL
Authorized Official - Prefix:
Authorized Official - First Name:GUILHERME
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLADARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-853-7107
Mailing Address - Street 1:PO BOX 824320
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-4320
Mailing Address - Country:US
Mailing Address - Phone:800-406-1177
Mailing Address - Fax:609-844-1092
Practice Address - Street 1:1 PLAINSBORO RD
Practice Address - Street 2:
Practice Address - City:PLAINSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08536-1913
Practice Address - Country:US
Practice Address - Phone:609-853-7600
Practice Address - Fax:609-853-7602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6172300Medicaid