1417018870 NPI number — THALODY MEDICAL ASSOCIATES LLC

Table of content: (NPI 1417018870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417018870 NPI number — THALODY MEDICAL ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THALODY MEDICAL ASSOCIATES 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:
1417018870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
240 WILLIAMSON ST
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
ELIZABETH
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07202-3672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-352-0560
Provider Business Mailing Address Fax Number:
908-352-4066

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 WILLIAMSON ST
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
ELIZABETH
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07202-3672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-352-0560
Provider Business Practice Location Address Fax Number:
908-352-4066
Provider Enumeration Date:
12/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
THALODY
Authorized Official First Name:
USA
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
908-352-0560

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 222232676 . This is a "TAX ID" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 7258607 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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