Healthcare Provider Details

I. General information

NPI: 1750441333
Provider Name (Legal Business Name): PROGRESSIVE PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 02/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3196 KENNEDY BLVD 3RD FLOOR
UNION CITY NJ
07087-2436
US

IV. Provider business mailing address

3196 KENNEDY BLVD 3RD FLOOR
UNION CITY NJ
07087-2436
US

V. Phone/Fax

Practice location:
  • Phone: 201-319-9800
  • Fax: 201-319-9849
Mailing address:
  • Phone: 201-319-9800
  • Fax: 201-319-9849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMA63880
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier0252573
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: DR. NOHA POLACK
Title or Position: PRESIDENT
Credential: MD
Phone: 201-319-9800