Basic Information
| Provider Information | |||||||||
| NPI: | 1669526190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRENTICE | ||||||||
| FirstName: | HUGH | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27957 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9088351910 | ||||||||
| FaxNumber: | 9088351924 | ||||||||
| Practice Location | |||||||||
| Address1: | 37 RUPELL RD | ||||||||
| Address2: | |||||||||
| City: | HAMPTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088274017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9087357060 | ||||||||
| FaxNumber: | 9087359922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 09/14/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MA51835 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1188503 | 05 | NJ | MEDICAID |