1215985544 NPI number — COASTAL JERSEY EYE CENTER LLC

Table of content: (NPI 1215985544)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215985544 NPI number — COASTAL JERSEY EYE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL JERSEY EYE CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1215985544
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2021 NEW ROAD
Provider Second Line Business Mailing Address:
STE 6
Provider Business Mailing Address City Name:
LINWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-927-3373
Provider Business Mailing Address Fax Number:
609-927-4041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2021 NEW ROAD
Provider Second Line Business Practice Location Address:
STE 6
Provider Business Practice Location Address City Name:
LINWOOD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-927-3373
Provider Business Practice Location Address Fax Number:
609-927-4041
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
URETSKY
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PROPRIETOR
Authorized Official Telephone Number:
609-927-3373

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1669921 . This is a "PPO AMERIHEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3724882 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 086183 . This is a "MEDICARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: DC5481 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 2345288000 . This is a "HMO AMERIHEALTH" identifier . This identifiers is of the category "OTHER".




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