MEDICARE: ROSEVILLE PEDIATRIC CARE CENTER, P.A.

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	MA034791	NJ

General Provider Information

NPI Number	:	1972638278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROSEVILLE PEDIATRIC CARE CENTER, P.A.

Provider Business Mailing Address
First Line	:	500 ORANGE ST
Second Line	:	SUITE 304
City	:	NEWARK
State	:	NJ
Zip	:	07107-2944
Country	:	US
Telephone Number	:	973-483-5529
Fax Number	:	973-481-0754

Provider Business Practice Location Address
First Line	:	500 ORANGE ST
Second Line	:	SUITE 304
City	:	NEWARK
State	:	NJ
Zip	:	07107-2944
Country	:	US
Telephone Number	:	973-483-5529
Fax Number	:	973-481-0754

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PONCIANO PALMIERY JR.
Credential	:	M.D.
Telephone Number	:	973-483-5529

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	12/03/2010

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