Provider Demographics
NPI:1861669244
Name:PRINCETON ROAD PEDIATRICS, PA
Entity Type:Organization
Organization Name:PRINCETON ROAD PEDIATRICS, PA
Other - Org Name:REBECCA F NOTTERMAN MD PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SITE/BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:ALICIA
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-448-8280
Mailing Address - Street 1:251 PRINCETON HIGHTSTOWN ROAD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:EAST WINDSOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08520
Mailing Address - Country:US
Mailing Address - Phone:609-448-8280
Mailing Address - Fax:609-395-1978
Practice Address - Street 1:251 PRINCETON HIGHTSTOWN ROAD
Practice Address - Street 2:SUITE 4
Practice Address - City:EAST WINDSOR
Practice Address - State:NJ
Practice Address - Zip Code:08520
Practice Address - Country:US
Practice Address - Phone:609-448-8280
Practice Address - Fax:609-395-1978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03948900208000000X, 2080P0203X, 261QP2300X
NJMA015133261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1857908Medicaid
NJ1857908Medicaid
NJ065947Medicare PIN