Basic Information
| Provider Information | |||||||||
| NPI: | 1093748089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VATTASSERIL | ||||||||
| FirstName: | RENJY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 593 | ||||||||
| Address2: | |||||||||
| City: | CAPE MAY COURT HOUSE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082100593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6094632755 | ||||||||
| FaxNumber: | 6094632757 | ||||||||
| Practice Location | |||||||||
| Address1: | 217 N MAIN ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CAPE MAY COURT HOUSE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082102165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6095368010 | ||||||||
| FaxNumber: | 6095368053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 09/22/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 239444 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 25MA08709900 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | P01227607 | 01 | NJ | RAILROAD MEDICARE | OTHER | 0232475 | 05 | NJ | MEDICAID |