1588631048 NPI number — GARY E STATMORE M.D.

Table of content: GARY E STATMORE M.D. (NPI 1588631048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588631048 NPI number — GARY E STATMORE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STATMORE
Provider First Name:
GARY
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1588631048
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
245 VALLEY BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOOD-RIDGE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07075-1236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-438-5500
Provider Business Mailing Address Fax Number:
201-438-3363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
245 VALLEY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOOD-RIDGE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07075-1236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-438-5500
Provider Business Practice Location Address Fax Number:
201-438-3363
Provider Enumeration Date:
03/03/2006

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: 207RG0100X , with the licence number:  25MA02277200 , 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: 529713 . This is a "AETNA HMO" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: BP481 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1458108 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5356729010 . This is a "CIGNA HMO PCP" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 5356729014 . This is a "CIGNA HMO SPECIALIST" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 486391 . This is a "AETNA PPO" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0K3970 . This is a "HEALTHNET" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0081399000 . This is a "AMERIHEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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