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NPI Code Detail

MEDICARE: RIVENDELL PEDIATRIC AND ADOLSCENT MEDICINE, PC

MEDICARE: RIVENDELL PEDIATRIC AND ADOLSCENT MEDICINE, PC
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
1208000000XPediatrics Physician25MA04122800NJ

General Provider Information

NPI Number : 1497797864
Entity Type Code : Organization
Provider Name (Legal Business Name) : RIVENDELL PEDIATRIC AND ADOLSCENT MEDICINE, PC
Provider Business Mailing Address
First Line : 25 HOMESTEAD DR
Second Line : STE H
City : COLUMBUS
State : NJ
Zip : 08022-1005
Country : US
Telephone Number : 609-424-0340
Fax Number : 609-298-7452
Provider Business Practice Location Address
First Line : 25 HOMESTEAD DR
Second Line : STE H
City : COLUMBUS
State : NJ
Zip : 08022-1005
Country : US
Telephone Number : 609-424-0340
Fax Number : 609-298-7452
Authorized Official
Title or Position : MD/PRES
Name : DR. KENNETH MICHAEL HIRSCH
Credential : MD
Telephone Number : 609-424-0340
Provider Enumeration Date : 06/12/2006
Last Update Date : 08/22/2020

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