Healthcare Provider Details

I. General information

NPI: 1194781591
Provider Name (Legal Business Name): JERSEY SHORE BETHANY PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 03/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BETHANY RD BUILDING 5: SUITE 65
HAZLET NJ
07730-1663
US

IV. Provider business mailing address

PO BOX 23674
NEWARK NJ
07189-0001
US

V. Phone/Fax

Practice location:
  • Phone: 732-264-0700
  • Fax: 732-264-1414
Mailing address:
  • Phone: 732-264-0700
  • Fax: 732-264-1414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CARL MARCHETTI
Title or Position: DIRECTOR
Credential: M.D.
Phone: 732-264-0700