1972044923 NPI number — MEDICAL SERVICE PROFESSIONALS OF NJ LLC

Table of content: (NPI 1972044923)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972044923 NPI number — MEDICAL SERVICE PROFESSIONALS OF NJ LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL SERVICE PROFESSIONALS OF NJ 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:
6
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:
1972044923
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 CHUBB AVE STE 100S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNDHURST
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07071-3504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 CHUBB AVE
Provider Second Line Business Practice Location Address:
SUITE 100-S
Provider Business Practice Location Address City Name:
LYNDHURST
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07071-3504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-559-7600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/10/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FONTANA
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF CLINICAL COMPLIANCE
Authorized Official Telephone Number:
631-457-9145

Provider Taxonomy Codes

  • Taxonomy code: 207QG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QH0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RH0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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