Provider Demographics
NPI:1326383076
Name:PASSAIC PEDIATRICS PA
Entity type:Organization
Organization Name:PASSAIC PEDIATRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:M
Authorized Official - Last Name:CAMILO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-233-3455
Mailing Address - Street 1:298 PASSAIC ST
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-5813
Mailing Address - Country:US
Mailing Address - Phone:973-249-8100
Mailing Address - Fax:973-249-8110
Practice Address - Street 1:200 GREGORY AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-3802
Practice Address - Country:US
Practice Address - Phone:973-249-8100
Practice Address - Fax:973-249-8110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA07167400208000000X
NJMA08000400208000000X
NJMA07649100208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1659418978Medicaid
NJ1497724819Medicaid
NJ1629047048Medicaid