1780866129 NPI number — PEDIATRICIAN IN MONROE

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 1780866129 NPI number — PEDIATRICIAN IN MONROE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRICIAN IN MONROE
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:
6
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:
1780866129
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13 SUMMERFIELD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08831-3275
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-561-7810
Provider Business Mailing Address Fax Number:
732-631-0742

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18 CENTRE DR
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08831-1501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-561-7810
Provider Business Practice Location Address Fax Number:
732-631-0742
Provider Enumeration Date:
11/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GEBRE MEDHIN
Authorized Official First Name:
HANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
PEDIATRICIAN
Authorized Official Telephone Number:
732-561-7810

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  25MA07639600 , 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: 0148695 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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