Provider Demographics
NPI:1063742765
Name:PICHARDO HEALTH GROUP P C
Entity type:Organization
Organization Name:PICHARDO HEALTH GROUP P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:R
Authorized Official - Last Name:PICHARDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-928-2167
Mailing Address - Street 1:80 PASSAIC AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-4860
Mailing Address - Country:US
Mailing Address - Phone:973-928-2167
Mailing Address - Fax:973-928-2170
Practice Address - Street 1:80 PASSAIC AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-4860
Practice Address - Country:US
Practice Address - Phone:973-928-2167
Practice Address - Fax:973-928-2170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-04
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03887500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0066885Medicaid