1912469321 NPI number — EDWIN RAFAEL FERNANDEZ GRULLON

Table of content: EDWIN RAFAEL FERNANDEZ GRULLON (NPI 1912469321)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912469321 NPI number — EDWIN RAFAEL FERNANDEZ GRULLON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERNANDEZ GRULLON
Provider First Name:
EDWIN
Provider Middle Name:
RAFAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1912469321
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
47 BAYSIDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAYONNE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07002-1278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-298-6665
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
47 BAYSIDE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAYONNE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07002-1278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-298-6665
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/03/2019

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: 224Z00000X , with the licence number:  46TA09163500 , 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)





Copyright © 2007-2024 www.npivalidator.com