1477624088 NPI number — NORTH HALEDON MEDICAL, PC

Table of content: (NPI 1477624088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477624088 NPI number — NORTH HALEDON MEDICAL, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH HALEDON MEDICAL, PC
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:
1477624088
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 HAMBURG TPKE
Provider Second Line Business Mailing Address:
WAYNE COMMONS, SUITE 101
Provider Business Mailing Address City Name:
WAYNE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07470-2025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-942-6005
Provider Business Mailing Address Fax Number:
973-942-6009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 HAMBURG TPKE
Provider Second Line Business Practice Location Address:
WAYNE COMMONS, SUITE 101
Provider Business Practice Location Address City Name:
WAYNE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07470-2025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-942-6005
Provider Business Practice Location Address Fax Number:
973-942-6009
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BARRAVECCHIO
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
Authorized Official Title or Position:
DELEGATED OFFICIAL
Authorized Official Telephone Number:
973-942-6005

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  25MB06978600 , 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: 2016615002 . This is a "AMERIHEALTH GROUP #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 7305262 . This is a "AETNA GROUP #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 8644101 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: DC3972 . This is a "RAILROAD MDCR GROUP #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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