1912144411 NPI number — MEDICAL DIVERSIFIED SERVICES, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912144411 NPI number — MEDICAL DIVERSIFIED SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL DIVERSIFIED SERVICES, INC.
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:
1912144411
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 442
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT MONMOUTH
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07758-0442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-787-4068
Provider Business Mailing Address Fax Number:
732-787-0632

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
196 HIGHWAY 36 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH MIDDLETOWN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07748-5258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-787-4068
Provider Business Practice Location Address Fax Number:
732-787-6032
Provider Enumeration Date:
01/21/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MURRAY
Authorized Official First Name:
KELLY- ANN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
732-787-0468

Provider Taxonomy Codes

  • Taxonomy code: 335V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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