1538221171 NPI number — PEDIATRIC PRACTICE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538221171 NPI number — PEDIATRIC PRACTICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC PRACTICE
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:
1538221171
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
127 PALISADE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JERSEY CITY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07306-1101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-217-1000
Provider Business Mailing Address Fax Number:
201-217-3118

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
127 PALISADE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JERSEY CITY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07306-1101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-217-1000
Provider Business Practice Location Address Fax Number:
201-217-3118
Provider Enumeration Date:
12/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MALIK
Authorized Official First Name:
TAYYABA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
201-217-1000

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  MA60432 , 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: 001 . This is a "PRUDENTIAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: HUL00007402 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1444591 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 491427 . This is a "AETNA US HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 551491 . This is a "EMPIRE BLUE CORSS BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6186106 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 13407 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 22943 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1010550 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2697096 . This is a "GHI (GROUP HEALTH CARE)" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2K3441 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: P2042267 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".




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