1750470761 NPI number — CORNERSTONE ASTHMA AND ALLERGY ASSOCIATES, L.L.C.

Table of content: (NPI 1750470761)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750470761 NPI number — CORNERSTONE ASTHMA AND ALLERGY ASSOCIATES, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORNERSTONE ASTHMA AND ALLERGY ASSOCIATES, L.L.C.
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:
1750470761
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 OLD MARLTON PIKE MEDFORD MEDICAL CENTER
Provider Second Line Business Mailing Address:
SUITE 211
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-953-7500
Provider Business Mailing Address Fax Number:
609-953-9085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 OLD MARLTON PIKE
Provider Second Line Business Practice Location Address:
SUITE 211
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08055-8772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-953-7500
Provider Business Practice Location Address Fax Number:
609-953-9085
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BANTZ
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
DR.
Authorized Official Telephone Number:
609-953-7500

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MA48238 , 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: 3373326 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 60012703 . This is a "HORIZON-MERCY" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 5312302 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010003124010 . This is a "AMERICHOICE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0350808000 . This is a "AMERIHEALTH HMO" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 147995 . This is a "PA BCBS PC" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 83386 . This is a "AMERIGROUP" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: J017341 . This is a "TRICARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P381888 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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