1174857809 NPI number — DR. KRISTINNE PETROLIS D.P.T

Table of content: DR. KRISTINNE PETROLIS D.P.T (NPI 1174857809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174857809 NPI number — DR. KRISTINNE PETROLIS D.P.T

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETROLIS
Provider First Name:
KRISTINNE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.P.T
Provider Gender Code:
F

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:
1174857809
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 EAGLE ROCK AVE
Provider Second Line Business Mailing Address:
201
Provider Business Mailing Address City Name:
EAST HANOVER
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07936-3167
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-887-9000
Provider Business Mailing Address Fax Number:
973-887-3816

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
720 ROUTE 202/206
Provider Second Line Business Practice Location Address:
1C
Provider Business Practice Location Address City Name:
BRIDGEWATER
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08807-1746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-231-2525
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2009

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: 225100000X , with the licence number:  40QA01327500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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