1902893134 NPI number — JAY V MALICKEL D.O.

Table of content: JAY V MALICKEL D.O. (NPI 1902893134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902893134 NPI number — JAY V MALICKEL D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALICKEL
Provider First Name:
JAY
Provider Middle Name:
V
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1902893134
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2284
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VINELAND
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08362-2284
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-358-6161
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
798 CENTERTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELMER
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08318-3945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-358-6161
Provider Business Practice Location Address Fax Number:
856-358-0142
Provider Enumeration Date:
10/03/2005

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: 207Q00000X , with the licence number:  MB06869400 , 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: 085366400 . This is a "AMERIHEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2325972 . This is a "AETNA/HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 60009045 . This is a "NJ HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7591121 . This is a "AETNA PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 223772973 . This is a "TAX ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8223904 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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