1235186164 NPI number — REGINA L ROSSI DO

Table of content: REGINA L ROSSI DO (NPI 1235186164)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235186164 NPI number — REGINA L ROSSI DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSSI
Provider First Name:
REGINA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OMRANI
Provider Other First Name:
REGINA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1235186164
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
195 ROUTE 9 SOUTH
Provider Second Line Business Mailing Address:
STE 108
Provider Business Mailing Address City Name:
MANALAPAN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-536-7144
Provider Business Mailing Address Fax Number:
732-536-7520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
195 ROUTE 9 SOUTH
Provider Second Line Business Practice Location Address:
STE 108
Provider Business Practice Location Address City Name:
MANALAPAN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-536-7144
Provider Business Practice Location Address Fax Number:
732-536-7520
Provider Enumeration Date:
05/27/2006

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: 207R00000X , with the licence number:  25MB06019200 , 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: 8646007 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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