1457547887 NPI number — NEW JERSEY KEYSTONE PHYSICIANS,LLC

Table of content: (NPI 1457547887)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457547887 NPI number — NEW JERSEY KEYSTONE PHYSICIANS,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW JERSEY KEYSTONE PHYSICIANS,LLC
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:
1457547887
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 115
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIDGEWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07451-0115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-447-3690
Provider Business Mailing Address Fax Number:
201-447-3691

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 E RIDGEWOOD AVE
Provider Second Line Business Practice Location Address:
WEST WING, SECOND FLOOR
Provider Business Practice Location Address City Name:
RIDGEWOOD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07450-3957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-447-3690
Provider Business Practice Location Address Fax Number:
201-447-3691
Provider Enumeration Date:
09/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PANAGIOTOU
Authorized Official First Name:
TINA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
201-447-3690

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  25MAO7320300 , 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: 087299 . This is a "MEDICARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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