MEDICARE: PEDSGASTRO CENTER LLC

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	2080P0206X	Pediatric Gastroenterology Physician	25MA08176100	NJ

General Provider Information

NPI Number	:	1336411958
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDSGASTRO CENTER LLC

Provider Business Mailing Address
First Line	:	15 LYNCH RD
Second Line	:
City	:	VOORHEES
State	:	NJ
Zip	:	08043-4116
Country	:	US
Telephone Number	:	856-874-6500
Fax Number	:	856-874-0512

Provider Business Practice Location Address
First Line	:	2123 KLOCKNER RD
Second Line	:
City	:	HAMILTON
State	:	NJ
Zip	:	08690-3417
Country	:	US
Telephone Number	:	609-586-7337
Fax Number	:	609-586-7338

Authorized Official
Title or Position	:	OWNER
Name	:	SABEENA FARHATH
Credential	:	MD
Telephone Number	:	856-874-6500

Provider Enumeration Date	:	01/27/2012
Last Update Date	:	02/01/2012

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Directions to “PEDSGASTRO CENTER LLC ” Practice Location

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