Healthcare Provider Details

I. General information

NPI: 1619074820
Provider Name (Legal Business Name): PRIMECARE PEDIATRICS, P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 LOCUST AVE
WALLINGTON NJ
07057-1300
US

IV. Provider business mailing address

42 LOCUST AVE
WALLINGTON NJ
07057-1300
US

V. Phone/Fax

Practice location:
  • Phone: 973-473-4033
  • Fax: 973-473-2988
Mailing address:
  • Phone: 973-473-4033
  • Fax: 973-473-2988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number25MA04953900
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name: STANISLAW SLIWOWSKI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 973-473-4033