1366685554 NPI number — MR. HENRY DUANE HAMILTON I LCADC, ICADC, CAMF

Table of content: DR. EILEEN BARBARA KRONENBERG D.M.D. (NPI 1023060670)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366685554 NPI number — MR. HENRY DUANE HAMILTON I LCADC, ICADC, CAMF

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAMILTON
Provider First Name:
HENRY
Provider Middle Name:
DUANE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
I
Provider Credential Text:
LCADC, ICADC, CAMF
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MUHAMMAD(HAMILTON)
Provider Other First Name:
HENRY
Provider Other Middle Name:
DUANE
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCADC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1366685554
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60 EVERGREEN PL STE 200&904
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST ORANGE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07018-2106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-678-3966
Provider Business Mailing Address Fax Number:
973-678-3968

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 EVERGREEN PL STE 200&904
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST ORANGE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-678-6015
Provider Business Practice Location Address Fax Number:
973-678-3968
Provider Enumeration Date:
04/17/2009

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: 101Y00000X , with the licence number:  37LC00118000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 37AC00086900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP1600X , with the licence number: 37CL00118000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 44SC05363800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RA0401X , with the licence number: 37LC00118000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: NO106752 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X , with the licence number: 37LC00118000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: 37LC00118000 , 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: 0491187 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0490717 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11890384 . This is a "CAQH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 8576195 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".