Provider Demographics
NPI:1750441333
Name:PROGRESSIVE PEDIATRICS
Entity type:Organization
Organization Name:PROGRESSIVE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NOHA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-319-9800
Mailing Address - Street 1:3196 KENNEDY BLVD
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-2436
Mailing Address - Country:US
Mailing Address - Phone:201-319-9800
Mailing Address - Fax:201-319-9849
Practice Address - Street 1:3196 KENNEDY BLVD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-2436
Practice Address - Country:US
Practice Address - Phone:201-319-9800
Practice Address - Fax:201-319-9849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA63880208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0252573Medicaid