1093394181 NPI number — APOLLO MEDICAL GROUP OF BLOOMFIELD LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093394181 NPI number — APOLLO MEDICAL GROUP OF BLOOMFIELD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
APOLLO MEDICAL GROUP OF BLOOMFIELD 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:
1093394181
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4366
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62708-4366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-360-1566
Provider Business Mailing Address Fax Number:
941-358-9818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1455 BROAD ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMFIELD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07003-3039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-402-2050
Provider Business Practice Location Address Fax Number:
201-402-2034
Provider Enumeration Date:
04/06/2021

Additional Information

Authorized Official

Authorized Official Last Name:
ELFAR
Authorized Official First Name:
AYMAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER/MANAGER
Authorized Official Telephone Number:
941-360-1566

Provider Taxonomy Codes

  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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