Provider Demographics
NPI:1104937259
Name:VINELAND PEDIATRICS PA
Entity type:Organization
Organization Name:VINELAND PEDIATRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCMASTER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:856-692-1108
Mailing Address - Street 1:1138 E CHESTNUT AVE #5B
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-5062
Mailing Address - Country:US
Mailing Address - Phone:856-692-1108
Mailing Address - Fax:856-692-2077
Practice Address - Street 1:1138 E CHESTNUT AVE #5B
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-5062
Practice Address - Country:US
Practice Address - Phone:856-692-1108
Practice Address - Fax:856-692-2077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0513129001OtherAMERIHEALTH HIPPA
679080OtherAMERIHEALTH
F03778OtherPHYSICIANS HEALTH
NJ1043187OtherHORIZON HEALTH
E337OtherAMERIGROUP
3041OtherAETNA
NJ3394603Medicaid
NJV1679080Medicare ID - Type Unspecified