1649240631 NPI number — DR. RANDYLL PAVIA MD

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 1649240631 NPI number — DR. RANDYLL PAVIA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAVIA
Provider First Name:
RANDYLL
Provider Middle Name:
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:
1649240631
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43 KENSICO DR
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
MOUNT KISCO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10549-1009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-666-8866
Provider Business Mailing Address Fax Number:
914-666-6777

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7600 RIVER RD
Provider Second Line Business Practice Location Address:
PALISADES MEDICAL CENTER
Provider Business Practice Location Address City Name:
NORTH BERGEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07047-6217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-854-5172
Provider Business Practice Location Address Fax Number:
201-854-5772
Provider Enumeration Date:
01/24/2006

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: 207L00000X , with the licence number:  MA08029400 , 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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