Provider Demographics
NPI:1063748747
Name:ANN UNIVERSITY PEDIATRICS, LLC
Entity type:Organization
Organization Name:ANN UNIVERSITY PEDIATRICS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:HONGYAN
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-257-8870
Mailing Address - Street 1:1259 RT 46 EAST, TROY OFFICE CENTER
Mailing Address - Street 2:SUITE 101, BUILDING 4C
Mailing Address - City:PARSIPPANY
Mailing Address - State:NJ
Mailing Address - Zip Code:07054
Mailing Address - Country:US
Mailing Address - Phone:873-257-8870
Mailing Address - Fax:973-257-8871
Practice Address - Street 1:1259 RT 46 EAST, TROY OFFICE CENTER
Practice Address - Street 2:SUITE 101, BUILDING 4C
Practice Address - City:PARSIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07054
Practice Address - Country:US
Practice Address - Phone:873-257-8870
Practice Address - Fax:973-257-8871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-30
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA071077207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8582301Medicaid
NJ8582301Medicaid