1831911395 NPI number — NEXT WAVE PEDIATRIC ENT LLC

Table of content: (NPI 1831911395)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831911395 NPI number — NEXT WAVE PEDIATRIC ENT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEXT WAVE PEDIATRIC ENT 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:
1831911395
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1940 ROUTE 70 E STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHERRY HILL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08003-2141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-696-5929
Provider Business Mailing Address Fax Number:
609-696-5619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1940 ROUTE 70 E STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHERRY HILL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08003-2141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-696-5929
Provider Business Practice Location Address Fax Number:
609-696-5619
Provider Enumeration Date:
10/28/2024

Additional Information

Authorized Official

Authorized Official Last Name:
WALKER
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
609-696-5929

Provider Taxonomy Codes

  • Taxonomy code: 207YP0228X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 25MA09871200 . This is a "NEW JERSEY BOARD OF MEDICAL EXAMINERS" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0514390 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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