Provider Demographics
NPI:1124105283
Name:NORTH JERSEY EAR NOSE & THROAT
Entity type:Organization
Organization Name:NORTH JERSEY EAR NOSE & THROAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEDRAZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-751-2251
Mailing Address - Street 1:36 NEWARK AVE
Mailing Address - Street 2:STE 318
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109
Mailing Address - Country:US
Mailing Address - Phone:973-751-2251
Mailing Address - Fax:973-751-4445
Practice Address - Street 1:36 NEWARK AVE
Practice Address - Street 2:STE 318
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109
Practice Address - Country:US
Practice Address - Phone:973-751-2251
Practice Address - Fax:973-751-4445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02443200207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1295501Medicaid
NJ040239Medicare ID - Type Unspecified
NJ1295501Medicaid