1790062628 NPI number — NON-SURGICAL ORTHOPEDICS OF NEW JERSEY

Table of content: (NPI 1790062628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790062628 NPI number — NON-SURGICAL ORTHOPEDICS OF NEW JERSEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NON-SURGICAL ORTHOPEDICS OF NEW JERSEY
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:
1790062628
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
465 WASHINGTON BLVD
Provider Second Line Business Mailing Address:
SUITE 2007 SOUTH
Provider Business Mailing Address City Name:
JERSEY CITY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07310-2117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-220-8960
Provider Business Mailing Address Fax Number:
516-717-3556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1107 CONVERY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PERTH AMBOY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08861-1937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-220-8960
Provider Business Practice Location Address Fax Number:
516-717-3556
Provider Enumeration Date:
11/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
VORA
Authorized Official First Name:
KETAN
Authorized Official Middle Name:
DHRUVKUMAR
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
516-220-8960

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  25MB08561100 , 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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