1306118294 NPI number — MOUNTAINSIDE ALLERGY AND IMMUNOLOGY GROUP

Table of content: (NPI 1306118294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306118294 NPI number — MOUNTAINSIDE ALLERGY AND IMMUNOLOGY GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAINSIDE ALLERGY AND IMMUNOLOGY GROUP
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:
1306118294
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19066
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95819-0066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-452-6222
Provider Business Mailing Address Fax Number:
916-451-5534

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4801 J ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95819-3746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-452-6222
Provider Business Practice Location Address Fax Number:
916-451-5534
Provider Enumeration Date:
02/07/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DEANE
Authorized Official First Name:
SEAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
916-452-6222

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GM857A . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: DT7846 . This is a "RAILROAD MEDICARE GROUP PTAN" identifier . This identifiers is of the category "OTHER".




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