1700840758 NPI number — RANDELL A NUSCHKE MD

Table of content: RANDELL A NUSCHKE MD (NPI 1700840758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700840758 NPI number — RANDELL A NUSCHKE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NUSCHKE
Provider First Name:
RANDELL
Provider Middle Name:
A
Provider Name Prefix Text:
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:
1700840758
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 593
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPE MAY COURT HOUSE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-967-0070
Provider Business Mailing Address Fax Number:
609-967-0077

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
336 96TH ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
STONE HARBOR
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08247-1439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-967-0070
Provider Business Practice Location Address Fax Number:
609-967-0077
Provider Enumeration Date:
04/14/2006

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:  25MA04738500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 200400287 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 1492 , registered in the state of VI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0108388000 . This is a "AMERIHEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3874206 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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