Healthcare Provider Details

I. General information

NPI: 1972565356
Provider Name (Legal Business Name): PEDIATRICS OF SOUTH BRUNSWICK PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 RIDGE RD SUITE 6
DAYTON NJ
08810-1398
US

IV. Provider business mailing address

395 RIDGE RD SUITE 6
DAYTON NJ
08810-1398
US

V. Phone/Fax

Practice location:
  • Phone: 732-274-2727
  • Fax: 732-274-1662
Mailing address:
  • Phone: 732-274-2727
  • Fax: 732-274-1662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS A GENCO
Title or Position: MD OWNER
Credential: MD
Phone: 732-274-2727