Provider Demographics
NPI:1831491885
Name:PEDIATRICS A1, LLC
Entity Type:Organization
Organization Name:PEDIATRICS A1, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAGI
Authorized Official - Middle Name:I
Authorized Official - Last Name:ELTEMSAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-222-7899
Mailing Address - Street 1:2775 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-5515
Mailing Address - Country:US
Mailing Address - Phone:201-222-7899
Mailing Address - Fax:
Practice Address - Street 1:2775 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-5515
Practice Address - Country:US
Practice Address - Phone:201-222-7899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-24
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06245800208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7082304Medicaid