Healthcare Provider Details

I. General information

NPI: 1851523674
Provider Name (Legal Business Name): ADVANCED PEDIATRICS GROUP, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2009
Last Update Date: 08/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 SUMMIT AVE SUITE 203
HACKENSACK NJ
07601-8503
US

IV. Provider business mailing address

17 RIVER RD APT D
NUTLEY NJ
07110-3465
US

V. Phone/Fax

Practice location:
  • Phone: 201-407-9421
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA07427800
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1093740458
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerNPI

VIII. Authorized Official

Name: DR. STEPHANIE DOS SANTOS
Title or Position: CO OWNER
Credential: M.D.
Phone: 201-407-9421