Provider Demographics
NPI:1669404018
Name:PEDIATRIC AFFILIATES PA
Entity type:Organization
Organization Name:PEDIATRIC AFFILIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:IANNACCONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-341-5180
Mailing Address - Street 1:40 BEY LEA ROAD
Mailing Address - Street 2:SUITE B203
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753
Mailing Address - Country:US
Mailing Address - Phone:732-341-0720
Mailing Address - Fax:732-244-6842
Practice Address - Street 1:40 BEY LEA ROAD
Practice Address - Street 2:SUITE B203
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753
Practice Address - Country:US
Practice Address - Phone:732-341-0720
Practice Address - Fax:732-244-6842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty