Basic Information
Provider Information | |||||||||
NPI: | 1518937564 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROWANSOM DEPT OF PULMONARY MEDICINE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 42 E LAUREL RD | ||||||||
Address2: | SUITE 3100 | ||||||||
City: | STRATFORD | ||||||||
State: | NJ | ||||||||
PostalCode: | 080841354 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8565666859 | ||||||||
FaxNumber: | 8565666952 | ||||||||
Practice Location | |||||||||
Address1: | 42 E LAUREL RD | ||||||||
Address2: | SUITE 3100 | ||||||||
City: | STRATFORD | ||||||||
State: | NJ | ||||||||
PostalCode: | 080841354 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8565666859 | ||||||||
FaxNumber: | 8565666952 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2006 | ||||||||
LastUpdateDate: | 05/03/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RIEKER | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | INTERIM CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8567705729 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 033918 | 01 | NJ | MEDICARE ID | OTHER | CD2384 | 01 | NJ | RR MEDICARE | OTHER | 33211 | 01 | NJ | AETNA | OTHER | 2453475000 | 01 |   | AMERIHEALTH | OTHER | 3152405 | 05 | NJ |   | MEDICAID |