Healthcare Provider Details

I. General information

NPI: 1245288000
Provider Name (Legal Business Name): PEDIATRIC NEPHROLOGY AT SAINT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 06/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 OLD SHORT HILLS RD
LIVINGSTON NJ
07039-5672
US

IV. Provider business mailing address

PO BOX 18239
NEWARK NJ
07191-8239
US

V. Phone/Fax

Practice location:
  • Phone: 973-322-5264
  • Fax: 973-322-2315
Mailing address:
  • Phone: 732-557-7160
  • Fax: 732-557-7109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. PATRICK AHEARN
Title or Position: DIRECTOR
Credential:
Phone: 732-557-7119