1407153455 NPI number — BEHAVIOR ANALYSTS OF NEW JERSEY

Table of content: ETHAN JAMES VANDEMARK MD (NPI 1205623386)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407153455 NPI number — BEHAVIOR ANALYSTS OF NEW JERSEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEHAVIOR ANALYSTS OF NEW JERSEY
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:
1407153455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 HILLCREST RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNTAIN LAKES
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07046-1327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-877-9757
Provider Business Mailing Address Fax Number:
737-267-6703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 HILLCREST RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN LAKES
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07046-1327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-877-9757
Provider Business Practice Location Address Fax Number:
737-267-6703
Provider Enumeration Date:
02/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
NIRGUDKAR
Authorized Official First Name:
ANJALEE
Authorized Official Middle Name:
SRIRAM
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
617-877-9757

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1841503042 . This is a "NATIONAL PROVIDER IDENTIFIER INDIVIDUAL" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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