1578730131 NPI number — BURLINGTON MERCER PODIATRY ASSOC LLC

Table of content: (NPI 1578730131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578730131 NPI number — BURLINGTON MERCER PODIATRY ASSOC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BURLINGTON MERCER PODIATRY ASSOC 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:
1578730131
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2089 KLOCKNER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRENTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08690-3416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-890-6544
Provider Business Mailing Address Fax Number:
856-795-0404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
226 BARBERRY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HADDONFIELD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08033-2705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-890-6544
Provider Business Practice Location Address Fax Number:
856-795-0404
Provider Enumeration Date:
05/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SULLIVAN
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
609-890-6544

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  25MD00267000 , 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: 8925704 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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