1003895798 NPI number — KELLY P KNOWLES MD

Table of content: KELLY P KNOWLES MD (NPI 1003895798)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003895798 NPI number — KELLY P KNOWLES MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KNOWLES
Provider First Name:
KELLY
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETRISON
Provider Other First Name:
KELLY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003895798
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
159 MILLBURN AVE
Provider Second Line Business Mailing Address:
STE 1
Provider Business Mailing Address City Name:
MILLBURN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07041-1849
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-912-0155
Provider Business Mailing Address Fax Number:
973-912-8714

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
159 MILLBURN AVE
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
MILLBURN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07041-1849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-912-0155
Provider Business Practice Location Address Fax Number:
973-912-8714
Provider Enumeration Date:
01/11/2006

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: 208000000X , with the licence number:  25MA06821100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2080A0000X , with the licence number: 25MA06821100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 010068211NJ01 . This is a "ANTHEM HEALTH PIN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2113135000 . This is a "AMERIHEALTH HMO PIN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1K7604 . This is a "HEALTHNET PIN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 956005 . This is a "AMERIHEALTH PPO GRP PIN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P2075112 . This is a "OXFORD PIN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 606914 . This is a "PHCS GRP ID" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: K4810 . This is a "BCBS MANAGED CARE PIN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0501095 . This is a "AETNA HMO GRP ID" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1997280 . This is a "UNITED HEALTH CARE PIN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 223285437 . This is a "BEECH ST GRP ID" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 7182328007 . This is a "CIGNA PIN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 4102R . This is a "WELL CHOICE PIN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 001427892 . This is a "HIGH MARK PA BLUE SHIELD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 223285437 . This is a "HCPCS GRP ID" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2532962 . This is a "AETNA HMO PIN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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