MEDICARE: PEDIATRIC CLINIC OF NORTH JERSEY

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	261QP2300X	Primary Care Clinic/Center	25MA04592000	NJ

General Provider Information

NPI Number	:	1538289038
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC CLINIC OF NORTH JERSEY

Provider Business Mailing Address
First Line	:	3524 JOHN F KENNEDY BLVD
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07307-3448
Country	:	US
Telephone Number	:	201-792-3022
Fax Number	:

Provider Business Practice Location Address
First Line	:	3524 JOHN F KENNEDY BLVD
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07307-3448
Country	:	US
Telephone Number	:	201-792-3022
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DR. FELICISIMA GABATIN BARRERA-TOLENTINO
Credential	:	MD
Telephone Number	:	201-792-3022

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	09/25/2007

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