1558546630 NPI number — POBLETE MEDICAL PRACTICE, PC

Table of content: (NPI 1558546630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558546630 NPI number — POBLETE MEDICAL PRACTICE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POBLETE MEDICAL PRACTICE, 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:
1558546630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
519 RIVER DR
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
GARFIELD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07026-3219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-253-7800
Provider Business Mailing Address Fax Number:
973-253-8503

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
519 RIVER DR
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
GARFIELD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07026-3219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-253-7800
Provider Business Practice Location Address Fax Number:
973-253-8503
Provider Enumeration Date:
01/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
POBLETE
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
973-253-7800

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4645405 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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