Basic Information
Provider Information | |||||||||
NPI: | 1427224328 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MYERS | ||||||||
FirstName: | WARD | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD, MPH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MYERS | ||||||||
OtherFirstName: | WARD | ||||||||
OtherMiddleName: | ALLEN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD, MPH | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 150 BERGEN ST | ||||||||
Address2: |   | ||||||||
City: | NEWARK | ||||||||
State: | NJ | ||||||||
PostalCode: | 071032496 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 150 BERGEN ST | ||||||||
Address2: |   | ||||||||
City: | NEWARK | ||||||||
State: | NJ | ||||||||
PostalCode: | 071032496 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9739729438 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2008 | ||||||||
LastUpdateDate: | 04/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 234339 | MA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 208000000X | 234339 | MA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 207P00000X | 25MA10773700 | NJ | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 110079271A | 05 | MA |   | MEDICAID |