Healthcare Provider Details

I. General information

NPI: 1528158409
Provider Name (Legal Business Name): EAST BRUNSWICK PEDIATRICS ASSOCIATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 02/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 BRUNSWICK WOODS DR
EAST BRUNSWICK NJ
08816-5601
US

IV. Provider business mailing address

33 BRUNSWICK WOODS DR
EAST BRUNSWICK NJ
08816-5601
US

V. Phone/Fax

Practice location:
  • Phone: 732-257-4330
  • Fax: 732-257-5986
Mailing address:
  • Phone: 732-257-4330
  • Fax: 732-257-5986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. COLLEEN L DOUGHERTY
Title or Position: BILLING DEPARTMENT
Credential:
Phone: 732-257-4330