1194757617 NPI number — PREMIUM MEDICAL CARE LLC

Table of content: (NPI 1194757617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194757617 NPI number — PREMIUM MEDICAL CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIUM MEDICAL CARE 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:
PREMIUM MEDICAL CARE LLC
Provider Other Organization Name Type Code:
3
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:
1194757617
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:
569 N 5TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07107-2630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-494-9706
Provider Business Mailing Address Fax Number:
973-954-4360

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 GRANDVIEW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PISCATAWAY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08854-2458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-494-9706
Provider Business Practice Location Address Fax Number:
973-954-4360
Provider Enumeration Date:
07/07/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROBINSON
Authorized Official First Name:
AARON
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
973-494-9706

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  44SC01309800 , 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: 25MA04542500 , 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: 25MA06248800 , 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: 25MA02906500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225100000X , with the licence number: 40QA00974100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225100000X , with the licence number: 40QA00647800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225X00000X , with the licence number: TR00324500 , 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)