1720044555 NPI number — INTERNET MEDICAL GROUP PC

Table of content: (NPI 1720044555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720044555 NPI number — INTERNET MEDICAL GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNET MEDICAL GROUP 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:
6
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:
1720044555
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 51051
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07101-5151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-667-8117
Provider Business Mailing Address Fax Number:
973-667-6642

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
181 FRANKLIN AVENUE
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
NUTLEY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-667-8117
Provider Business Practice Location Address Fax Number:
973-667-6642
Provider Enumeration Date:
04/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VECCHIONE
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
973-667-8117

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X , with the licence number: 25MA07282700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 31D0108495 . This is a "CLIA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 6342205 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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