Provider Demographics
NPI:1942384888
Name:PASSAIC PEDIATRICS PA
Entity Type:Organization
Organization Name:PASSAIC PEDIATRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD-OWNER-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMILO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-249-8100
Mailing Address - Street 1:298 PASSAIC STREET
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055
Mailing Address - Country:US
Mailing Address - Phone:973-249-8100
Mailing Address - Fax:973-249-8110
Practice Address - Street 1:298 PASSAIC STREET
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055
Practice Address - Country:US
Practice Address - Phone:973-249-8100
Practice Address - Fax:973-249-8110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06599400208000000X
208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0044245Medicaid
NJ8407304Medicaid
NJ8220701Medicaid
NJ0117056Medicaid
NJ8407509Medicaid
NJ0044253Medicaid