1336298389 NPI number — NORTHFIELD INTERNAL MEDICINE, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336298389 NPI number — NORTHFIELD INTERNAL MEDICINE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHFIELD INTERNAL MEDICINE, PA
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:
1336298389
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13 BLUE BIRD CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANDOLPH
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07869-2127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-992-0658
Provider Business Mailing Address Fax Number:
973-992-6655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 E NORTHFIELD RD
Provider Second Line Business Practice Location Address:
SUITE # 1D
Provider Business Practice Location Address City Name:
LIVINGSTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07039-4896
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-992-0658
Provider Business Practice Location Address Fax Number:
973-992-6655
Provider Enumeration Date:
01/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NANDURI
Authorized Official First Name:
VISALA
Authorized Official Middle Name:
V
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
973-328-6736

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0110515 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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