1720030315 NPI number — DR. PHILLIP ASHLEY WACKYM MD

Table of content: DR. PHILLIP ASHLEY WACKYM MD (NPI 1720030315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720030315 NPI number — DR. PHILLIP ASHLEY WACKYM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WACKYM
Provider First Name:
PHILLIP
Provider Middle Name:
ASHLEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WACKYM
Provider Other First Name:
P. ASHLEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1720030315
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 PLUM STREET, 5TH FLOOR
Provider Second Line Business Mailing Address:
DEPARTMENT OF OTOLARYNGOLOGY-HEAD AND NECK SURGERY
Provider Business Mailing Address City Name:
NEW BRUNSWICK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-235-5530
Provider Business Mailing Address Fax Number:
732-565-9751

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 PLUM ST FL 5
Provider Second Line Business Practice Location Address:
DEPARTMENT OF OTOLARYNGOLOGY - HEAD AND NECK SURGERY
Provider Business Practice Location Address City Name:
NEW BRUNSWICK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08901-2066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-235-5530
Provider Business Practice Location Address Fax Number:
732-565-9751
Provider Enumeration Date:
05/16/2006

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: 207YS0123X , with the licence number:  25MA09934900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207YX0901X , with the licence number: 25MA09934900 , 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)





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