Provider Demographics
NPI:1679892533
Name:MYSTIC ISLAND PEDIATRIC ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MYSTIC ISLAND PEDIATRIC ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:DR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:CHIU
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-294-5500
Mailing Address - Street 1:104 E ANCHOR DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE EGG HARBOR TWP
Mailing Address - State:NJ
Mailing Address - Zip Code:08087-1643
Mailing Address - Country:US
Mailing Address - Phone:609-294-5500
Mailing Address - Fax:609-294-5700
Practice Address - Street 1:104 E ANCHOR DR
Practice Address - Street 2:
Practice Address - City:LITTLE EGG HARBOR TWP
Practice Address - State:NJ
Practice Address - Zip Code:08087-1643
Practice Address - Country:US
Practice Address - Phone:609-294-5500
Practice Address - Fax:609-294-5700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05073700261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty