Provider Demographics
NPI:1790868503
Name:PEDIATRIC ASSOCIATES LLC
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:LORENTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-691-8585
Mailing Address - Street 1:1318 S MAIN ROAD
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360
Mailing Address - Country:US
Mailing Address - Phone:856-691-8585
Mailing Address - Fax:856-691-8489
Practice Address - Street 1:1318 S MAIN ROAD
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360
Practice Address - Country:US
Practice Address - Phone:856-691-8585
Practice Address - Fax:856-691-8489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4525604Medicaid