1174613079 NPI number — MARK A MENEGUS MD

Table of content: MARK A MENEGUS MD (NPI 1174613079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174613079 NPI number — MARK A MENEGUS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENEGUS
Provider First Name:
MARK
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174613079
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16 EHRET AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARRINGTON PK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07640-1202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-920-5528
Provider Business Mailing Address Fax Number:
718-920-7447

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MMC - DEPT. OF CARDIOLOGY
Provider Second Line Business Practice Location Address:
111 EAST 210TH STREET
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-920-5528
Provider Business Practice Location Address Fax Number:
718-920-7447
Provider Enumeration Date:
10/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  152562 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)