Basic Information
| Provider Information | |||||||||
| NPI: | 1790769487 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAVELL | ||||||||
| FirstName: | JEFF | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076314967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015672277 | ||||||||
| FaxNumber: | 2015677506 | ||||||||
| Practice Location | |||||||||
| Address1: | 365 ROUTE 304 | ||||||||
| Address2: | STE 102 | ||||||||
| City: | BARDONIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109541601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456242182 | ||||||||
| FaxNumber: | 8456242188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 10/29/2012 | ||||||||
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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 | 208100000X | 202584 | NY | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | MB69881 | NJ | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 804550 | 05 | NJ | MEDICAID | DO7698000 | 01 | NJ | CDS | OTHER | 8P5694143 | 01 | NY | DEA | OTHER | 8P6614994 | 01 | NJ | DEA | OTHER |