Provider Demographics
NPI:1700915592
Name:NORTH JERSEY PEDIATRIC ORTHPEDICS PA
Entity Type:Organization
Organization Name:NORTH JERSEY PEDIATRIC ORTHPEDICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:AVELLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-445-2457
Mailing Address - Street 1:140 CHESTNUT ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-2599
Mailing Address - Country:US
Mailing Address - Phone:210-445-2457
Mailing Address - Fax:201-445-9050
Practice Address - Street 1:140 CHESTNUT ST
Practice Address - Street 2:SUITE 201
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-2599
Practice Address - Country:US
Practice Address - Phone:210-445-2457
Practice Address - Fax:201-445-9050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA39087207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1822900Medicaid
NJ3333604Medicaid
NJ3Q4361OtherBCBS
NJ9483401Medicaid
NJ81D031OtherBCBS
NJMA063207Medicare PIN
NJ1822900Medicaid