MEDICARE: SUSSEX COUNTY PEDIATRIC ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center

General Provider Information

NPI Number	:	1114071024
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUSSEX COUNTY PEDIATRIC ASSOCIATES

Provider Business Mailing Address
First Line	:	2 MYRTLE DRIVE
Second Line	:
City	:	MONTAGUE
State	:	NJ
Zip	:	07827
Country	:	US
Telephone Number	:	973-293-7579
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 MYRTLE DRIVE
Second Line	:
City	:	MONTAGUE
State	:	NJ
Zip	:	07827
Country	:	US
Telephone Number	:	973-293-7579
Fax Number	:

Authorized Official
Title or Position	:	TREASURER
Name	:	DR. JAMES PORTER
Credential	:
Telephone Number	:	973-293-7579

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	01/17/2008

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