1548848906 NPI number — MY HOME TELEMED LLC

Table of content: (NPI 1548848906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548848906 NPI number — MY HOME TELEMED LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MY HOME TELEMED 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:
1548848906
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 ANITA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EGG HARBOR TOWNSHIP
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08234-7522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-432-5417
Provider Business Mailing Address Fax Number:
609-788-8111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1156 PIEDMONT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VENICE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34293-4843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-432-5417
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/29/2021

Additional Information

Authorized Official

Authorized Official Last Name:
TRUMBAUER
Authorized Official First Name:
DENISE
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER, CEO
Authorized Official Telephone Number:
609-432-5417

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 60062926 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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