Provider Demographics
NPI:1447675186
Name:GALLOWAY PEDIATRICS, LLC
Entity type:Organization
Organization Name:GALLOWAY PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN-PEDIATRICS
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ-BERNARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-748-2800
Mailing Address - Street 1:53 W WHITE HORSE PIKE STE D
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-9450
Mailing Address - Country:US
Mailing Address - Phone:609-748-2800
Mailing Address - Fax:609-748-6721
Practice Address - Street 1:53 W WHITE HORSE PIKE STE D
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9450
Practice Address - Country:US
Practice Address - Phone:609-748-2800
Practice Address - Fax:609-748-6721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07514000305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0081175Medicaid