Provider Demographics
NPI:1861660219
Name:JERSEY CITY PEDIATRICS
Entity Type:Organization
Organization Name:JERSEY CITY PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BANDANA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-963-0090
Mailing Address - Street 1:1 JOURNAL SQUARE PLZ
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-4004
Mailing Address - Country:US
Mailing Address - Phone:201-963-0090
Mailing Address - Fax:
Practice Address - Street 1:1 JOURNAL SQUARE PLZ
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-4004
Practice Address - Country:US
Practice Address - Phone:201-963-0090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA41101305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5475805Medicaid