1386675718 NPI number — NORTHERN MECIAL CENTER PC

Table of content: (NPI 1386675718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386675718 NPI number — NORTHERN MECIAL CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN MECIAL CENTER PC
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:
1386675718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
51 W PROSPECT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST BRUNSWICK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08816-5711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-238-3800
Provider Business Mailing Address Fax Number:
732-238-2883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51 W PROSPECT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST BRUNSWICK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08816-5711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-238-3800
Provider Business Practice Location Address Fax Number:
732-238-2883
Provider Enumeration Date:
07/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MATCHIN
Authorized Official First Name:
MIRA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
732-238-3800

Provider Taxonomy Codes

  • Taxonomy code: 207QG0300X , with the licence number:  MA 039611 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207R00000X , with the licence number: 25MA07937500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207R00000X , with the licence number: 25MB07663700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 213E00000X , with the licence number: 25MD00274100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 011574 . This is a "GHI" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 4704191 . This is a "CIGNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1115857 . This is a "HORIZON" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 8706808 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8942404 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: P3729381 . This is a "UNITEDHEALTHCARE OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 7024826 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".