1154672632 NPI number — SERENA I BASCIANO PT, MSPT

Table of content: SERENA I BASCIANO PT, MSPT (NPI 1154672632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154672632 NPI number — SERENA I BASCIANO PT, MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASCIANO
Provider First Name:
SERENA
Provider Middle Name:
I
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, MSPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FORBES
Provider Other First Name:
SERENA
Provider Other Middle Name:
I
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154672632
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1014
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07066-1014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-855-9751
Provider Business Mailing Address Fax Number:
732-855-9755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
266-272 CHESTNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07105-6521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-732-3850
Provider Business Practice Location Address Fax Number:
973-732-3853
Provider Enumeration Date:
09/25/2012

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: 225100000X , with the licence number:  40QA01443500 , 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: 049801DBD . This is a "MEDICARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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