Basic Information
Provider Information | |||||||||
NPI: | 1215090345 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RODIA | ||||||||
FirstName: | MAUREEN | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHYSICIAN ASSISTANT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GRAY | ||||||||
OtherFirstName: | MAUREEN | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 75 VERONICA AVE | ||||||||
Address2: | SUITE 101 | ||||||||
City: | SOMERSET | ||||||||
State: | NJ | ||||||||
PostalCode: | 08873 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7322477444 | ||||||||
FaxNumber: | 7322475119 | ||||||||
Practice Location | |||||||||
Address1: | 1 ROBERT WOOD JOHNSON PL | ||||||||
Address2: | ROBERT WOOD JOHNSON UNIVERSITY HOSPITAL - NEW BRUNSWICK | ||||||||
City: | NEW BRUNSWICK | ||||||||
State: | NJ | ||||||||
PostalCode: | 089011928 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7322358717 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/19/2006 | ||||||||
LastUpdateDate: | 03/31/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X |   |   | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.