1790871812 NPI number — PEDIATRIC DAY HLTH CTR GALLOW

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 1790871812 NPI number — PEDIATRIC DAY HLTH CTR GALLOW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC DAY HLTH CTR GALLOW
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:
1790871812
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1114 WYNNWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHERRY HILL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08002-3256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-663-4044
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
66 W JIMMIE LEEDS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALLOWAY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08205-9401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-748-9100
Provider Business Practice Location Address Fax Number:
609-748-9300
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SALL
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
J
Authorized Official Title or Position:
C.E.O.
Authorized Official Telephone Number:
856-663-4044

Provider Taxonomy Codes

  • Taxonomy code: 261QM3000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0103616 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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