1992954887 NPI number — OAK TREE FAMILY PRACTICE, LLC

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 1992954887 NPI number — OAK TREE FAMILY PRACTICE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OAK TREE FAMILY PRACTICE, LLC
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:
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:
1992954887
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
173 ESSEX AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
METUCHEN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08840-2281
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-321-5100
Provider Business Mailing Address Fax Number:
732-321-5252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
173 ESSEX AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
METUCHEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08840-2281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-321-5100
Provider Business Practice Location Address Fax Number:
732-321-5252
Provider Enumeration Date:
09/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
AHN
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
732-321-5100

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  25MB06391200 , 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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