1992807705 NPI number — DR. JAIME A BASTIDAS M.D.

Table of content: DR. JAIME A BASTIDAS M.D. (NPI 1992807705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992807705 NPI number — DR. JAIME A BASTIDAS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASTIDAS
Provider First Name:
JAIME
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1992807705
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
244 ROSEBERRY ST.
Provider Second Line Business Mailing Address:
SUITE #5
Provider Business Mailing Address City Name:
PHILLIPSBURG
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08865
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-454-1704
Provider Business Mailing Address Fax Number:
908-454-1706

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
244 ROSEBERRY ST.
Provider Second Line Business Practice Location Address:
SUITE #5
Provider Business Practice Location Address City Name:
PHILLIPSBURG
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08865
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-454-1704
Provider Business Practice Location Address Fax Number:
908-454-1706
Provider Enumeration Date:
09/02/2006

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: 174400000X , with the licence number:  MD422370 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: 25MA07689900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0122X , with the licence number: MD422370 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2086S0122X , with the licence number: 25MA07689900 , 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: 074448ZH1E . This is a "MEDICARE PTAN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 074448UK1 . This is a "MEDICARE PTAN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 073750 . This is a "MEDICARE PTAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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