1053365973 NPI number — ON-SITE SPECIALTY CARE, LLC

Table of content: (NPI 1053365973)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053365973 NPI number — ON-SITE SPECIALTY CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ON-SITE SPECIALTY CARE, 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:
1053365973
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 EAST NEW CASTLE ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCEAN CITY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08226-4725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-602-2908
Provider Business Mailing Address Fax Number:
856-231-9699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3001 E EVESHAM RD
Provider Second Line Business Practice Location Address:
ON-SITE SPECIALTY CARE-CRNP
Provider Business Practice Location Address City Name:
VOORHEES
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08043-9547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-613-9614
Provider Business Practice Location Address Fax Number:
253-663-7737
Provider Enumeration Date:
05/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PETILLO
Authorized Official First Name:
FLORIA
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
610-613-9614

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0018016410002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8186308 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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