Basic Information
Provider Information | |||||||||
NPI: | 1578015798 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ISD TRENTON LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PHYSICIANS DIALYSIS LAWRENCEVILLE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 19559 NE 10TH AVE | ||||||||
Address2: |   | ||||||||
City: | NORTH MIAMI BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 331793501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3056513261 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1840 PRINCETON AVE | ||||||||
Address2: |   | ||||||||
City: | LAWRENCEVILLE | ||||||||
State: | NJ | ||||||||
PostalCode: | 086484518 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6092780999 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/04/2016 | ||||||||
LastUpdateDate: | 03/26/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JEGER | ||||||||
AuthorizedOfficialFirstName: | STEVEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP | ||||||||
AuthorizedOfficialTelephone: | 3056513261 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PHYSICIANS DIALYSIS LAWRENCEVILLE | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/26/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 24287 | NJ | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.