Provider Demographics
NPI:1790132140
Name:PINELANDS PEDIATRIC MEDICINE LLC
Entity Type:Organization
Organization Name:PINELANDS PEDIATRIC MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:KAUS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-885-4854
Mailing Address - Street 1:1303 LIBERTY PL
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-5710
Mailing Address - Country:US
Mailing Address - Phone:856-885-4854
Mailing Address - Fax:856-885-4896
Practice Address - Street 1:1303 LIBERTY PL
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-5710
Practice Address - Country:US
Practice Address - Phone:856-885-4854
Practice Address - Fax:856-885-4896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08379900208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ167193Medicaid