MEDICARE: PEDIATRIC MULTICARE

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	261QP2300X	Primary Care Clinic/Center	25MA05857400	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700028438
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC MULTICARE

Provider Business Mailing Address
First Line	:	525 WANAQUE AVE
Second Line	:
City	:	POMPTON LAKES
State	:	NJ
Zip	:	07442-1843
Country	:	US
Telephone Number	:	973-685-4411
Fax Number	:

Provider Business Practice Location Address
First Line	:	525 WANAQUE AVE
Second Line	:
City	:	POMPTON LAKES
State	:	NJ
Zip	:	07442-1843
Country	:	US
Telephone Number	:	973-685-4411
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	DR. VERA BENNETT
Credential	:	MD
Telephone Number	:	973-685-4411

Provider Enumeration Date	:	03/26/2009
Last Update Date	:	03/26/2009

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