Basic Information
| Provider Information | |||||||||
| NPI: | 1992894091 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHERN VALLEY OBA, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7111 FAIRWAY DR | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334184204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616232000 | ||||||||
| FaxNumber: | 8652913612 | ||||||||
| Practice Location | |||||||||
| Address1: | 375 ENGLE ST | ||||||||
| Address2: | SECOND FLOOR | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076311823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018716073 | ||||||||
| FaxNumber: | 2018710619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 01/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | WEISS | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5616232000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | DC9942 | 01 | NJ | RAILROAD MEDICARE | OTHER | 0078891 | 05 | NJ | MEDICAID |