Healthcare Provider Details

I. General information

NPI: 1609990043
Provider Name (Legal Business Name): PEDIATRIC URGICARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 OVERLOOK RD SUITE 101
SUMMIT NJ
07901-3570
US

IV. Provider business mailing address

33 OVERLOOK RD SUITE 101
SUMMIT NJ
07901-3570
US

V. Phone/Fax

Practice location:
  • Phone: 908-918-1666
  • Fax: 908-918-9449
Mailing address:
  • Phone: 908-918-1666
  • Fax: 908-918-9449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL POLISIN
Title or Position: OWNER
Credential: MD
Phone: 908-918-1666