Healthcare Provider Details

I. General information

NPI: 1841291242
Provider Name (Legal Business Name): AZZARITI, KOLSKY PEDIMEDICA PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 PALISADE AVE
TEANECK NJ
07666-3419
US

IV. Provider business mailing address

870 PALISADE AVE STE 204
TEANECK NJ
07666-3419
US

V. Phone/Fax

Practice location:
  • Phone: 201-692-1661
  • Fax: 201-692-9219
Mailing address:
  • Phone: 201-692-1661
  • Fax: 201-692-9219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA06103000
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier628804
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: DR. GEORGE M. AZZARITI
Title or Position: PRESIDENT
Credential: MD
Phone: 201-291-2323