1124186853 NPI number — NORTH WAYNE PEDIATRICS

Table of content: (NPI 1124186853)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124186853 NPI number — NORTH WAYNE PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH WAYNE PEDIATRICS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124186853
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
508 HAMBURG TPKE STE 106
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAYNE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07470-8482
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-942-7800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
508 HAMBURG TPKE STE 106
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAYNE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07470-8482
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-942-7800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRUCZYNSKI
Authorized Official First Name:
TOMASZ
Authorized Official Middle Name:
ADAM
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
973-942-7800

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  MA059789 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9044400 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com