1497993646 NPI number — BLUE SKY MEDICAL LLC

Table of content: (NPI 1497993646)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497993646 NPI number — BLUE SKY MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE SKY MEDICAL 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:
1497993646
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
67 LACEY RD
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
WHITING
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08759-2912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-849-0707
Provider Business Mailing Address Fax Number:
732-849-0016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
67 LACEY RD
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
WHITING
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08759-2912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-849-0707
Provider Business Practice Location Address Fax Number:
732-849-0016
Provider Enumeration Date:
01/27/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CHOPER
Authorized Official First Name:
JOAN
Authorized Official Middle Name:
Z
Authorized Official Title or Position:
M.D.
Authorized Official Telephone Number:
732-849-0707

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  25MA06506800 , 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: 25MA06506800 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 7852509 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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