MEDICARE: WILLOWBROOK PEDIATRICS

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	2080A0000X	Pediatric Adolescent Medicine Physician

General Provider Information

NPI Number	:	1154388403
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOWBROOK PEDIATRICS

Provider Business Mailing Address
First Line	:	57 WILLOWBROOK BLVD
Second Line	:	SUITE 421
City	:	WAYNE
State	:	NJ
Zip	:	07470-7045
Country	:	US
Telephone Number	:	973-754-4025
Fax Number	:	973-754-4044

Provider Business Practice Location Address
First Line	:	57 WILLOWBROOK BLVD
Second Line	:	SUITE 421
City	:	WAYNE
State	:	NJ
Zip	:	07470-7045
Country	:	US
Telephone Number	:	973-754-4025
Fax Number	:	973-754-4044

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PATRICIA PAPADOPOULOS
Credential	:	M.D.
Telephone Number	:	973-754-4025

Provider Enumeration Date	:	04/28/2006
Last Update Date	:	07/12/2007

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