Provider Demographics
NPI:1588697940
Name:SOUTHERN OCEAN PEDIATRIC ASSOCIATES, P.C.
Entity type:Organization
Organization Name:SOUTHERN OCEAN PEDIATRIC ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:NIEWIADOMSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-978-8900
Mailing Address - Street 1:1100 ROUTE 72 W
Mailing Address - Street 2:SUITE 304
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-2468
Mailing Address - Country:US
Mailing Address - Phone:609-978-9639
Mailing Address - Fax:609-978-9685
Practice Address - Street 1:1100 ROUTE 72 W
Practice Address - Street 2:SUITE 304
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2468
Practice Address - Country:US
Practice Address - Phone:609-978-9639
Practice Address - Fax:609-978-9685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0067067Medicaid
NJ091761Medicare ID - Type UnspecifiedGROUP NUMBER