Healthcare Provider Details

I. General information

NPI: 1104031939
Provider Name (Legal Business Name): ELIZABETH PEDIATRIC GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 NEWARK AVE SUITE 212
ELIZABETH NJ
07208-3550
US

IV. Provider business mailing address

701 NEWARK AVE SUITE 212
ELIZABETH NJ
07208-3550
US

V. Phone/Fax

Practice location:
  • Phone: 908-354-9500
  • Fax: 908-354-9077
Mailing address:
  • Phone: 908-354-9500
  • Fax: 908-354-9077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA04177300
License Number StateNJ

VIII. Authorized Official

Name: DR. KENNETH JAMES DAVIS
Title or Position: OWNER
Credential: MD
Phone: 908-354-9500