1386685162 NPI number — PARK MEDICAL GROUP PA

Table of content: (NPI 1386685162)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386685162 NPI number — PARK MEDICAL GROUP PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARK MEDICAL GROUP 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:
1386685162
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 ELM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARRINGTON PARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07640-1902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-784-0123
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24 ELM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARRINGTON PARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07640-1902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-784-0123
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRUNNQUELL
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
Authorized Official Title or Position:
DELEGATED OFFICIAL
Authorized Official Telephone Number:
201-784-0123

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  25MA05743400 , 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: 0048302001 . This is a "KEYSTONE GROUP #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0048302002 . This is a "AMERIHEALTH GROUP # T" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0048302004 . This is a "AMERIHEALTH GROUP # NV" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: CB3927 . This is a "RRMDCR GROUP #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0048302001 . This is a "AMERIHEALTH GROUP # HP" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 7298803 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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