Basic Information
| Provider Information | |||||||||
| NPI: | 1568028314 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PAI PARTICIPANT 25 PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 639676 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452639676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592914800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 290 RED SCHOOL LN | ||||||||
| Address2: | |||||||||
| City: | PHILLIPSBURG | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088652276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9088592800 | ||||||||
| FaxNumber: | 9088594532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2019 | ||||||||
| LastUpdateDate: | 08/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | LAIRD | ||||||||
| AuthorizedOfficialFirstName: | ERIN | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 4104588713 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.