1750349395 NPI number — DR. ANISE A KACHADOURIAN MD

Table of content: DR. ANISE A KACHADOURIAN MD (NPI 1750349395)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750349395 NPI number — DR. ANISE A KACHADOURIAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KACHADOURIAN
Provider First Name:
ANISE
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
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:
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:
1750349395
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
776 E 3RD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSELLE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07203-1698
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-259-8817
Provider Business Mailing Address Fax Number:
908-259-8846

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
776 E 3RD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSELLE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07203-1698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-259-8817
Provider Business Practice Location Address Fax Number:
908-259-8846
Provider Enumeration Date:
05/03/2006

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: 207RH0003X , with the licence number:  MA71654 , 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)

  • Identifier: 9113304 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 25MA07165400 . This is a "CDS" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 207RH0003X . This is a "TAXONOMY CODE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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