1518035625 NPI number — KENNETH GIRVAN SWAN JR. MD

Table of content: MRS. TARA HARRIS LMP (NPI 1124752456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518035625 NPI number — KENNETH GIRVAN SWAN JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SWAN
Provider First Name:
KENNETH
Provider Middle Name:
GIRVAN
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1518035625
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 WORLDS FAIR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOMERSET
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08873-1369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-504-3649
Provider Business Mailing Address Fax Number:
732-564-9032

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
740 ROUTE 1 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ISELIN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08830-2652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-853-8610
Provider Business Practice Location Address Fax Number:
732-885-3862
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207XX0005X , with the licence number:  25MA07516000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 25MA07516000 , 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)





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