1558369579 NPI number — AUDREY F VON POELNITZ MD

Table of content: AUDREY F VON POELNITZ MD (NPI 1558369579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558369579 NPI number — AUDREY F VON POELNITZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VON POELNITZ
Provider First Name:
AUDREY
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STERN
Provider Other First Name:
AUDREY
Provider Other Middle Name:
F
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1558369579
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 416457
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02241-6457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
435 SOUTH ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MORRISTOWN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07960-6440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-267-3944
Provider Business Practice Location Address Fax Number:
973-455-0399
Provider Enumeration Date:
07/13/2005

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:  25MA05556800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0011X , with the licence number: 25MA05556800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 4572700 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".