Provider Demographics
NPI:1679521504
Name:PEDIATRIC SPECIALTY GROUP AT THE AMBULATORY CARE CENTER
Entity Type:Organization
Organization Name:PEDIATRIC SPECIALTY GROUP AT THE AMBULATORY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:ESPOSITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-557-7160
Mailing Address - Street 1:PO BOX 18456
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07191-8456
Mailing Address - Country:US
Mailing Address - Phone:732-557-7160
Mailing Address - Fax:732-557-7109
Practice Address - Street 1:200 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5817
Practice Address - Country:US
Practice Address - Phone:973-322-7623
Practice Address - Fax:973-322-7698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Multi-Specialty
Not Answered2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric NephrologyGroup - Multi-Specialty
Not Answered2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8850003Medicaid