1427354505 NPI number — WESTSIDE PODIATRIC ASSOCIATES 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 1427354505 NPI number — WESTSIDE PODIATRIC ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTSIDE PODIATRIC 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:
1427354505
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
85 STELLING AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAYWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07607-2135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-491-2173
Provider Business Mailing Address Fax Number:
201-586-0202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 W CENTURY RD
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
PARAMUS
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07652-1433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-491-2173
Provider Business Practice Location Address Fax Number:
201-586-0202
Provider Enumeration Date:
02/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LUONGO
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
201-491-2173

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  2517 , 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)





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