Provider Demographics
NPI:1679580781
Name:PEDIATRIC SURGERY GROUP, LLC
Entity Type:Organization
Organization Name:PEDIATRIC SURGERY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:COLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BETHEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-660-9334
Mailing Address - Street 1:25B VREELAND RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FLORHAM PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07932-1900
Mailing Address - Country:US
Mailing Address - Phone:973-660-9334
Mailing Address - Fax:973-660-9732
Practice Address - Street 1:2130 MILLBURN AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3725
Practice Address - Country:US
Practice Address - Phone:973-313-3115
Practice Address - Fax:973-313-3188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Single Specialty