Healthcare Provider Details

I. General information

NPI: 1801925466
Provider Name (Legal Business Name): HOLLY CITY PEDIATRICS,PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 04/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 EAST MAIN ST HOLLY CITY PEDIATRICS SUITE A
MILLVILLE NJ
08332
US

IV. Provider business mailing address

10 EAST MAIN ST HOLLY CITY PEDIATRICS SUITE A
MILLVILLE NJ
08332
US

V. Phone/Fax

Practice location:
  • Phone: 856-825-5932
  • Fax: 856-825-4819
Mailing address:
  • Phone: 856-825-5932
  • Fax: 856-825-4819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA6269600
License Number StateNJ

VIII. Authorized Official

Name: LILY SERRANO
Title or Position: OFFICE MANAGER
Credential:
Phone: 856-825-5932