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General NPI Number Information
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NPI Number | 1215179312
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Entity Type | Organization
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Legal Business Name | PEDIARIC CENTER 2000 INC
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Dates
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Enumeration Date | 04/03/2009
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Last Update Date | 04/03/2009
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Provider Practice Location Address
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Address Line | 571 N 6TH ST
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City | NEWARK
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State | NJ
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Zip | 07107-2501
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Country | US
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Telephone | 973-485-5401
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Fax | 973-485-1536
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Provider Business Mailing Address
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Address Line | 1079 PLEASANT VALLEY WAY
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City | WEST ORANGE
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State | NJ
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Zip | 07052-1418
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Country | US
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Telephone | 973-485-5401
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Fax | 973-485-1536
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Authorized Official
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Title or Position | PRESIDENT
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Name | JESUS RUBEN ORTEGA
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Credential | MD
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Telephone | 973-484-5401
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number | 25MA06060600
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License Number State | NJ
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