Provider Demographics
NPI:1730475088
Name:ESSEX PEDIDOC, LLC
Entity Type:Organization
Organization Name:ESSEX PEDIDOC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNIER
Authorized Official - Middle Name:
Authorized Official - Last Name:LAUREDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-371-1600
Mailing Address - Street 1:22 BALL ST STE 100
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-3521
Mailing Address - Country:US
Mailing Address - Phone:973-371-1600
Mailing Address - Fax:
Practice Address - Street 1:22 BALL ST STE 100
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3521
Practice Address - Country:US
Practice Address - Phone:973-371-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-24
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05388700305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization