1508050139 NPI number — PROGRESSIVE PODIATRY OF NORTH JERSEY

Table of content: (NPI 1508050139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508050139 NPI number — PROGRESSIVE PODIATRY OF NORTH JERSEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROGRESSIVE PODIATRY OF NORTH JERSEY
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:
1508050139
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
725 RIVER RD
Provider Second Line Business Mailing Address:
SUITE 201-A
Provider Business Mailing Address City Name:
EDGEWATER
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07020-1171
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-840-7373
Provider Business Mailing Address Fax Number:
201-840-7383

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 RIVER RD
Provider Second Line Business Practice Location Address:
SUITE 201-A
Provider Business Practice Location Address City Name:
EDGEWATER
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07020-1171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-840-7373
Provider Business Practice Location Address Fax Number:
201-840-7383
Provider Enumeration Date:
08/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GEHEGAN
Authorized Official First Name:
CORINNE
Authorized Official Middle Name:
JEANETTE
Authorized Official Title or Position:
SOLE OWNER
Authorized Official Telephone Number:
201-840-7373

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  25MD00272100 , 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: 1508050139 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6481920001 . This is a "MEDICARE/CMS DME (PTAN)" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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