1245437755 NPI number — TERRYLEE MAIMONE O.D, P.C

Table of content: (NPI 1245437755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245437755 NPI number — TERRYLEE MAIMONE O.D, P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TERRYLEE MAIMONE O.D, P.C
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:
1245437755
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
32-01 BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIR LAWN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07410-4616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-703-2922
Provider Business Mailing Address Fax Number:
201-791-6626

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
32-01 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIR LAWN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07410-4616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-703-2922
Provider Business Practice Location Address Fax Number:
201-791-6626
Provider Enumeration Date:
06/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MAIMONE
Authorized Official First Name:
TERRYLEE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
201-703-2922

Provider Taxonomy Codes

  • Taxonomy code: 152WV0400X , with the licence number:  27TO00040600 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 27OA00490500 , 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: C228E1 . This is a "EMPIRE BCBS" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 5452503 . This is a "CCN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 177820 . This is a "CHN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2319156 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2K3806 . This is a "HEALTHNET" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P2865102 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2099723 . This is a "FIRST HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 518967 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 4495272 . This is a "CIGNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 6018700 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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