1578562245 NPI number — DR. ROBIN R INNELLA D.O.

Table of content: DR. ROBIN R INNELLA D.O. (NPI 1578562245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578562245 NPI number — DR. ROBIN R INNELLA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
INNELLA
Provider First Name:
ROBIN
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1578562245
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 STUYVESANT AVE
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
UNION
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07083-6936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-964-6600
Provider Business Mailing Address Fax Number:
908-364-1025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 STUYVESANT AVE
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
UNION
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07083-6936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-964-6600
Provider Business Practice Location Address Fax Number:
908-364-1025
Provider Enumeration Date:
07/15/2005

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: 207X00000X , with the licence number:  MB42873 , 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: 1439103 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4257897 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 222279894 . This is a "CIGNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 222279894 . This is a "BLUE SHIELD OF NJ" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0043114 . This is a "GHI" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: HS218 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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