Provider Demographics
NPI:1689630162
Name:NEW BRUNSWICK PEDIATRIC GROUP, P.A.
Entity Type:Organization
Organization Name:NEW BRUNSWICK PEDIATRIC GROUP, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:DIEMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-247-1510
Mailing Address - Street 1:1300 HOW LN
Mailing Address - Street 2:PO BOX 6017
Mailing Address - City:NORTH BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902-1721
Mailing Address - Country:US
Mailing Address - Phone:732-247-1510
Mailing Address - Fax:732-247-8885
Practice Address - Street 1:1300 HOW LN
Practice Address - Street 2:
Practice Address - City:NORTH BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08902-1721
Practice Address - Country:US
Practice Address - Phone:732-247-1510
Practice Address - Fax:732-247-8885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2645009Medicaid