1467496687 NPI number — DR. NICHOLAS L DEPACE MD

Table of content: DR. NICHOLAS L DEPACE MD (NPI 1467496687)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467496687 NPI number — DR. NICHOLAS L DEPACE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEPACE
Provider First Name:
NICHOLAS
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1467496687
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
438 GANTTOWN RD
Provider Second Line Business Mailing Address:
SUITES B8-B9
Provider Business Mailing Address City Name:
SEWELL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08080-1887
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-589-6034
Provider Business Mailing Address Fax Number:
856-589-6036

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
438 GANTTOWN RD
Provider Second Line Business Practice Location Address:
SUITES B8-B9
Provider Business Practice Location Address City Name:
SEWELL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08080
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-589-6034
Provider Business Practice Location Address Fax Number:
856-589-6036
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  25MA03627300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: MD023597E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: MD023597E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207UN0901X , with the licence number: 25MA03627300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207UN0901X , with the licence number: MD023597E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 25MA03627300 , 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: 0229598000 . This is a "KEYSTONE HEALTH PLAN EAST" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1048118 . This is a "HORIZON NJ HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 4100717 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 530072 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P3785506 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0229598000 . This is a "PERSONAL CHOICE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 5264103 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01004610300 . This is a "AMERICHOICE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0229598000 . This is a "AMERIHEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0154010 . This is a "GHI" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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