Provider Demographics
NPI:1154571222
Name:FAYROUZ PEDIATRIC LLC
Entity type:Organization
Organization Name:FAYROUZ PEDIATRIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HISHAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:GADALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-928-3388
Mailing Address - Street 1:238 OLD WAGON ROAD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07417-1626
Mailing Address - Country:US
Mailing Address - Phone:973-928-3388
Mailing Address - Fax:973-928-3388
Practice Address - Street 1:540 STRAIGHT STREET SECOND FLOOR 2E
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503
Practice Address - Country:US
Practice Address - Phone:973-928-3388
Practice Address - Fax:973-928-3388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-25
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA075893208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty