Provider Demographics
NPI:1801925466
Name:HOLLY CITY PEDIATRICS,PA
Entity type:Organization
Organization Name:HOLLY CITY PEDIATRICS,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LILY
Authorized Official - Middle Name:
Authorized Official - Last Name:SERRANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-825-5932
Mailing Address - Street 1:10 EAST MAIN ST HOLLY CITY PEDIATRICS
Mailing Address - Street 2:SUITE A
Mailing Address - City:MILLVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08332
Mailing Address - Country:US
Mailing Address - Phone:856-825-5932
Mailing Address - Fax:856-825-4819
Practice Address - Street 1:10 EAST MAIN ST HOLLY CITY PEDIATRICS
Practice Address - Street 2:SUITE A
Practice Address - City:MILLVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08332
Practice Address - Country:US
Practice Address - Phone:856-825-5932
Practice Address - Fax:856-825-4819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA6269600208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7684801Medicaid