Healthcare Provider Details

I. General information

NPI: 1639251804
Provider Name (Legal Business Name): QUALITY CARE PEDIATRIX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 CHANCELLOR AVE
NEWARK NJ
07112
US

IV. Provider business mailing address

88 CHANCELLOR AVE
NEWARK NJ
07112
US

V. Phone/Fax

Practice location:
  • Phone: 973-926-4400
  • Fax: 973-926-4660
Mailing address:
  • Phone: 973-926-4400
  • Fax: 973-926-4660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMA61110
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier6467105
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: DR. IBILOLA IGHAMA-AMEGOR
Title or Position: AAD DIRECTOR
Credential: MD
Phone: 973-926-4400