1790977056 NPI number — NEW JERSEY ELECTROPHYSIOLOGY ASSOCIATES LLC

Table of content: (NPI 1790977056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790977056 NPI number — NEW JERSEY ELECTROPHYSIOLOGY ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW JERSEY ELECTROPHYSIOLOGY ASSOCIATES LLC
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:
1790977056
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 LYONS AVE
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:
07112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-926-8590
Provider Business Mailing Address Fax Number:
973-926-6758

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 LYONS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-926-8590
Provider Business Practice Location Address Fax Number:
973-926-6758
Provider Enumeration Date:
08/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROTHBART
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
TOBIAS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
973-926-8590

Provider Taxonomy Codes

  • Taxonomy code: 207RC0001X , with the licence number:  MA35123 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0001X , with the licence number: MA03512300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 09385M4V . This is a "MEDICARE ID" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 8437807 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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