1063503555 NPI number — DR. SAMUEL A BANIGO M.D.,

Table of content: DR. SAMUEL A BANIGO M.D., (NPI 1063503555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063503555 NPI number — DR. SAMUEL A BANIGO M.D.,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BANIGO
Provider First Name:
SAMUEL
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.,
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JENKINS
Provider Other First Name:
DIANA
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OFFICE MANAGER
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1063503555
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 INDEPENDENCE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSELLE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07203-2410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-245-3637
Provider Business Mailing Address Fax Number:
973-375-5766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 UNION AVE
Provider Second Line Business Practice Location Address:
STE.204
Provider Business Practice Location Address City Name:
IRVINGTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07111-3277
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-416-6981
Provider Business Practice Location Address Fax Number:
973-375-5766
Provider Enumeration Date:
09/27/2006

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: 207RA0000X , with the licence number:  25MA07986300 , 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: 0098256 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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