Provider Demographics
NPI:1790845113
Name:PEDI GROUP,PA
Entity Type:Organization
Organization Name:PEDI GROUP,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:DR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:BAUTISTA
Authorized Official - Last Name:MESINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-679-6650
Mailing Address - Street 1:2695 COUNTY ROAD 516
Mailing Address - Street 2:BROWNTOWN SHOPPING CENTER
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-2319
Mailing Address - Country:US
Mailing Address - Phone:732-679-6650
Mailing Address - Fax:732-679-6620
Practice Address - Street 1:2695 COUNTY ROAD 516
Practice Address - Street 2:BROWNTOWN SHOPPING CENTER
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-2319
Practice Address - Country:US
Practice Address - Phone:732-679-6650
Practice Address - Fax:732-679-6620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06034900208000000X
NJ25MA06092500208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6224903Medicaid
NJ6186301Medicaid
NJME620438Medicare ID - Type UnspecifiedDR. LEON B. MESINA
NJ6186301Medicaid
NJAS620353Medicare ID - Type UnspecifiedDR. CLARO M. ASPREC
NJ6224903Medicaid