Basic Information
| Provider Information | |||||||||
| NPI: | 1588808000 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEPHROLOGY CONSULTANTS OF NJ, LLC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | NEPHROLOGY CONSULTANTS OF NJ, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1050 GEORGE ST | ||||||||
| Address2: | APT: 6G | ||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089011012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9178482318 | ||||||||
| FaxNumber: | 7322120713 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 HOLLY ST | ||||||||
| Address2: | |||||||||
| City: | CRANFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070162158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082724711 | ||||||||
| FaxNumber: | 7322120713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2009 | ||||||||
| LastUpdateDate: | 11/02/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | IMBRIANO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7322120051 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 25MB08272700 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 0162850 | 05 | NJ | MEDICAID |