Provider Demographics
NPI:1538221171
Name:PEDIATRIC PRACTICE
Entity type:Organization
Organization Name:PEDIATRIC PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TAYYABA
Authorized Official - Middle Name:K
Authorized Official - Last Name:MALIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-217-1000
Mailing Address - Street 1:127 PALISADE AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-1101
Mailing Address - Country:US
Mailing Address - Phone:201-217-1000
Mailing Address - Fax:201-217-3118
Practice Address - Street 1:127 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-1101
Practice Address - Country:US
Practice Address - Phone:201-217-1000
Practice Address - Fax:201-217-3118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA60432208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
001OtherPRUDENTIAL
NJHUL00007402Medicaid
1444591OtherUNITED HEALTH CARE
491427OtherAETNA US HEALTHCARE
551491OtherEMPIRE BLUE CORSS BS
NJ6186106Medicaid
NJ13407Medicaid
NJ22943Medicaid
NJ1010550Medicaid
2697096OtherGHI (GROUP HEALTH CARE)
NJ2K3441Medicaid
P2042267OtherOXFORD
=========OtherCIGNA
=========OtherPHCS
1444591OtherUNITED HEALTH CARE
NJ22943Medicaid
NJ2K3441Medicaid
=========OtherCIGNA
NJ2K3441Medicaid