Provider Demographics
NPI:1790726628
Name:MONMOUTH PEDIATRIC GROUP, P.A.
Entity Type:Organization
Organization Name:MONMOUTH PEDIATRIC GROUP, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WASSEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-741-0456
Mailing Address - Street 1:272 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-2003
Mailing Address - Country:US
Mailing Address - Phone:732-741-0456
Mailing Address - Fax:732-219-9477
Practice Address - Street 1:272 BROAD ST
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-2003
Practice Address - Country:US
Practice Address - Phone:732-741-0456
Practice Address - Fax:732-219-9477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2661004Medicaid