Healthcare Provider Details

I. General information

NPI: 1790845113
Provider Name (Legal Business Name): PEDI GROUP,PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2695 COUNTY ROAD 516 BROWNTOWN SHOPPING CENTER
OLD BRIDGE NJ
08857-2319
US

IV. Provider business mailing address

2695 COUNTY ROAD 516 BROWNTOWN SHOPPING CENTER
OLD BRIDGE NJ
08857-2319
US

V. Phone/Fax

Practice location:
  • Phone: 732-679-6650
  • Fax: 732-679-6620
Mailing address:
  • Phone: 732-679-6650
  • Fax: 732-679-6620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA06034900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA06092500
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier6224903
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 2
Identifier6186301
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: DR. LEON BAUTISTA MESINA
Title or Position: VP
Credential: M.D.
Phone: 732-679-6650