MEDICARE: SANTA CLARA PEDIATRIC CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	25MA08433000	NJ

General Provider Information

NPI Number	:	1285880047
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANTA CLARA PEDIATRIC CORPORATION

Provider Business Mailing Address
First Line	:	7524 KENNEDY BLVD
Second Line	:
City	:	NORTH BERGEN
State	:	NJ
Zip	:	07047-4037
Country	:	US
Telephone Number	:	201-758-0290
Fax Number	:

Provider Business Practice Location Address
First Line	:	7524 KENNEDY BLVD
Second Line	:
City	:	NORTH BERGEN
State	:	NJ
Zip	:	07047-4037
Country	:	US
Telephone Number	:	201-758-0290
Fax Number	:

Authorized Official
Title or Position	:	MEDICINE DOCTOR
Name	:	DAMARIS ALEJANDRA EGUINO CONDE
Credential	:	M.D
Telephone Number	:	201-758-0290

Provider Enumeration Date	:	08/13/2008
Last Update Date	:	08/13/2008

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Directions to “SANTA CLARA PEDIATRIC CORPORATION ” Practice Location

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