Healthcare Provider Details

I. General information

NPI: 1245438431
Provider Name (Legal Business Name): NORTHEAST PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 N 12TH ST SUITE E
LEHIGHTON PA
18235-1101
US

IV. Provider business mailing address

281 N 12TH ST SUITE E
LEHIGHTON PA
18235-1101
US

V. Phone/Fax

Practice location:
  • Phone: 610-377-6969
  • Fax:
Mailing address:
  • Phone: 610-377-6969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD022461E
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier00571402
Identifier TypeMEDICAID
Identifier StatePA
Identifier IssuerMEDICAID

VIII. Authorized Official

Name: DR. L.NARAYANA GAJULA
Title or Position: OWNER
Credential: M.D.
Phone: 610-377-6969