1518967249 NPI number — JOHN MANICONE

Table of content: JOHN MANICONE (NPI 1518967249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518967249 NPI number — JOHN MANICONE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANICONE
Provider First Name:
JOHN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1518967249
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
225 MILLBURN AVE
Provider Second Line Business Mailing Address:
SUITE 104B
Provider Business Mailing Address City Name:
MILLBURN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07041-1737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-379-5888
Provider Business Mailing Address Fax Number:
973-912-9757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 MILLBURN AVE
Provider Second Line Business Practice Location Address:
SUITE 104B
Provider Business Practice Location Address City Name:
MILLBURN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07041-1737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-379-5888
Provider Business Practice Location Address Fax Number:
973-912-9757
Provider Enumeration Date:
07/22/2005

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: 174400000X , with the licence number:  25MA05569400 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 25MA05569400 , 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: 5710066 . This is a "GHI PPO #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 84168 . This is a "AMERIGROUP #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0526328000 . This is a "AMERIHEALTH #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0K3218 . This is a "HEALTHNET #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 5093166 . This is a "AETNA PPO #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1059497 . This is a "HORIZON NJ HEALTH #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 575898 . This is a "AETNA HMO #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 6893201 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 770001140 . This is a "RAILROAD MDCR #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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