Provider Demographics
NPI:1790188472
Name:PEDIATRIC FAMILY HEALTH CENTER LLC
Entity Type:Organization
Organization Name:PEDIATRIC FAMILY HEALTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REPRESENTATIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICJA
Authorized Official - Middle Name:T
Authorized Official - Last Name:UCZKOWSKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-726-0565
Mailing Address - Street 1:399 WEST MOUNTAIN RD.
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-1003
Mailing Address - Country:US
Mailing Address - Phone:973-726-0565
Mailing Address - Fax:974-579-0016
Practice Address - Street 1:10 MORAN ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860-1806
Practice Address - Country:US
Practice Address - Phone:973-940-0407
Practice Address - Fax:973-579-0016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-08
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07239500208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0480690Medicaid
NJ145746279OtherHACKENSACK UNIVERSITY MEDICAL CENTAR
NJ145746279OtherHACKENSACK UNIVERSITY MEDICAL CENTAR
NJ66041Medicare PIN