1790188472 NPI number — PEDIATRIC FAMILY HEALTH CENTER LLC

Table of content: (NPI 1790188472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790188472 NPI number — PEDIATRIC FAMILY HEALTH CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC FAMILY HEALTH CENTER LLC
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:
1790188472
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
399 WEST MOUNTAIN RD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPARTA
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07871-1003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-726-0565
Provider Business Mailing Address Fax Number:
974-579-0016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 MORAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07860-1806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-940-0407
Provider Business Practice Location Address Fax Number:
973-579-0016
Provider Enumeration Date:
10/08/2014

Additional Information

Authorized Official

Authorized Official Last Name:
UCZKOWSKA
Authorized Official First Name:
ALICJA
Authorized Official Middle Name:
T
Authorized Official Title or Position:
REPRESENTATIVE
Authorized Official Telephone Number:
973-726-0565

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  25MA07239500 , 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: 0480690 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 145746279 . This is a "HACKENSACK UNIVERSITY MEDICAL CENTAR" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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