Healthcare Provider Details

I. General information

NPI: 1114071024
Provider Name (Legal Business Name): SUSSEX COUNTY PEDIATRIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 01/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MYRTLE DRIVE
MONTAGUE NJ
07827
US

IV. Provider business mailing address

2 MYRTLE DRIVE
MONTAGUE NJ
07827
US

V. Phone/Fax

Practice location:
  • Phone: 973-293-7579
  • Fax:
Mailing address:
  • Phone: 973-293-7579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES PORTER
Title or Position: TREASURER
Credential:
Phone: 973-293-7579