Provider Demographics
NPI:1700028438
Name:PEDIATRIC MULTICARE
Entity Type:Organization
Organization Name:PEDIATRIC MULTICARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VERA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-685-4411
Mailing Address - Street 1:525 WANAQUE AVE
Mailing Address - Street 2:
Mailing Address - City:POMPTON LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07442-1843
Mailing Address - Country:US
Mailing Address - Phone:973-685-4411
Mailing Address - Fax:
Practice Address - Street 1:525 WANAQUE AVE
Practice Address - Street 2:
Practice Address - City:POMPTON LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07442-1843
Practice Address - Country:US
Practice Address - Phone:973-685-4411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-26
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05857400261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6171109Medicaid
NJ6171109Medicaid