Provider Demographics
NPI:1245288000
Name:PEDIATRIC NEPHROLOGY AT SAINT
Entity type:Organization
Organization Name:PEDIATRIC NEPHROLOGY AT SAINT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:AHEARN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-557-7119
Mailing Address - Street 1:PO BOX 18239
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07191-8239
Mailing Address - Country:US
Mailing Address - Phone:732-557-7160
Mailing Address - Fax:732-557-7109
Practice Address - Street 1:94 OLD SHORT HILLS RD
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5672
Practice Address - Country:US
Practice Address - Phone:973-322-5264
Practice Address - Fax:973-322-2315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric NephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7383207Medicaid
NJ003171Medicare ID - Type UnspecifiedGROUP