Basic Information
Provider Information | |||||||||
NPI: | 1679511208 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SUPE | ||||||||
FirstName: | DANA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 TRENTON RD | ||||||||
Address2: |   | ||||||||
City: | BROWNS MILLS | ||||||||
State: | NJ | ||||||||
PostalCode: | 080151705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6098931200 | ||||||||
FaxNumber: | 6097350175 | ||||||||
Practice Location | |||||||||
Address1: | 200 TRENTON RD | ||||||||
Address2: | DEPT. OF SURGERY | ||||||||
City: | BROWNS MILLS | ||||||||
State: | NJ | ||||||||
PostalCode: | 080151705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6098931200 | ||||||||
FaxNumber: | 6097350175 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2006 | ||||||||
LastUpdateDate: | 12/16/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/16/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25MA06493000 | NJ | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RC0200X | 25MA06493000 | NJ | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RS0012X | 25MA06493000 | NJ | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RP1001X | 25MA06493000 | NJ | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 8780102 | 05 | NJ |   | MEDICAID |