Provider Demographics
NPI:1811232762
Name:PEDI PRACTICES
Entity Type:Organization
Organization Name:PEDI PRACTICES
Other - Org Name:PEDIATRIC PRACTICE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO/ SOLER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAYYABA
Authorized Official - Middle Name:K
Authorized Official - Last Name:MALIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-217-1000
Mailing Address - Street 1:127 PALISADE AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-1101
Mailing Address - Country:US
Mailing Address - Phone:201-217-1000
Mailing Address - Fax:201-217-3118
Practice Address - Street 1:127 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-1101
Practice Address - Country:US
Practice Address - Phone:201-217-1000
Practice Address - Fax:201-217-3118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-04
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA060432261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ491427OtherAETNA
NJ001OtherPRUDENTIAL
NJ551491OtherEMPIRE BLUE CROSS BLUE SHIELD
NJ2K3441Medicaid
NJ2697096OtherGHI
NJHUL00007402Medicaid
NJ551491OtherEMPIRE BLUE CROSS BLUE SHIELD
NJHUL00007402Medicaid