Healthcare Provider Details

I. General information

NPI: 1750752135
Provider Name (Legal Business Name): GLEN ROCK PEDIATRICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2015
Last Update Date: 10/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 S MAPLE AVE SUITE 107A
GLEN ROCK NJ
07452-1543
US

IV. Provider business mailing address

385 S MAPLE AVE SUITE 107A
GLEN ROCK NJ
07452-1543
US

V. Phone/Fax

Practice location:
  • Phone: 201-857-3111
  • Fax: 201-857-3110
Mailing address:
  • Phone: 201-857-3111
  • Fax: 201-857-3110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number25MA09074400
License Number StateNJ

VIII. Authorized Official

Name: DR. DORINA HALIFMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 201-857-3111