1881680742 NPI number — GARY J MASCILAK PT

Table of content: GARY J MASCILAK PT (NPI 1881680742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881680742 NPI number — GARY J MASCILAK PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASCILAK
Provider First Name:
GARY
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1881680742
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 LAFAYETTE RD
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
SPARTA
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-729-0291
Provider Business Mailing Address Fax Number:
973-729-6710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 LAFAYETTE RD ROUTE 15 SO
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SPARTA
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07871
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-940-8680
Provider Business Practice Location Address Fax Number:
973-940-8634
Provider Enumeration Date:
09/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  38MC00455100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , with the licence number: 40QA00611400 , 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: 8380406 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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