1356468821 NPI number — MS. GEORGINE MAE POOLE OTR

Table of content: MS. GEORGINE MAE POOLE OTR (NPI 1356468821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356468821 NPI number — MS. GEORGINE MAE POOLE OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POOLE
Provider First Name:
GEORGINE
Provider Middle Name:
MAE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

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:
1356468821
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 N MAPLE AVE APT 61
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARLTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08053-1717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-751-1600
Provider Business Mailing Address Fax Number:
856-489-4150

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31 NORTH MAPLE AVENUE
Provider Second Line Business Practice Location Address:
APT 61
Provider Business Practice Location Address City Name:
MARLTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-751-1600
Provider Business Practice Location Address Fax Number:
856-489-4150
Provider Enumeration Date:
03/22/2007

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: 225X00000X , with the licence number:  46TR00092200 , 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)





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