Provider Demographics
NPI:1023431871
Name:PROSPECT PEDIATRICS PA
Entity type:Organization
Organization Name:PROSPECT PEDIATRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:FIDELIS
Authorized Official - Middle Name:
Authorized Official - Last Name:OKOH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-356-1696
Mailing Address - Street 1:P.O. BOX 1268
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003
Mailing Address - Country:US
Mailing Address - Phone:973-356-1696
Mailing Address - Fax:
Practice Address - Street 1:163 BELLEVILLE AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-2437
Practice Address - Country:US
Practice Address - Phone:973-302-4644
Practice Address - Fax:973-528-2242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-30
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty