Healthcare Provider Details

I. General information

NPI: 1427640440
Provider Name (Legal Business Name): WASHINGTON ST PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 N 13TH ST
NEWARK NJ
07107-1317
US

IV. Provider business mailing address

495 N 13TH ST
NEWARK NJ
07107-1317
US

V. Phone/Fax

Practice location:
  • Phone: 973-268-5862
  • Fax:
Mailing address:
  • Phone: 973-268-5862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL SKOLNICK
Title or Position: OWNER
Credential:
Phone: 973-715-5963