1104875947 NPI number — DR. RICHARD J DEGROOTE II M.D.

Table of content: DR. RICHARD J DEGROOTE II M.D. (NPI 1104875947)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104875947 NPI number — DR. RICHARD J DEGROOTE II M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEGROOTE
Provider First Name:
RICHARD
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
II
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:
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:
1104875947
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8000
Provider Second Line Business Mailing Address:
DEPT 601
Provider Business Mailing Address City Name:
BUFFALO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14267-0002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-295-0041
Provider Business Mailing Address Fax Number:
708-342-2517

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 2ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BRANCH
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07740-6303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-923-7100
Provider Business Practice Location Address Fax Number:
732-923-7104
Provider Enumeration Date:
05/09/2006

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:  25MA03004300 , 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: 1859102 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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