Basic Information
| Provider Information | |||||||||
| NPI: | 1790132140 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINELANDS PEDIATRIC MEDICINE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1303 LIBERTY PL | ||||||||
| Address2: | |||||||||
| City: | SICKLERVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080815710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568854854 | ||||||||
| FaxNumber: | 8568854896 | ||||||||
| Practice Location | |||||||||
| Address1: | 1303 LIBERTY PL | ||||||||
| Address2: | |||||||||
| City: | SICKLERVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080815710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568854854 | ||||||||
| FaxNumber: | 8568854896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2016 | ||||||||
| LastUpdateDate: | 05/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | KAUS | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8568854854 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 25MB08379900 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 167193 | 05 | NJ | MEDICAID |