Provider Demographics
NPI:1063649168
Name:WOMENS HEALTHCARE PAVILLION PA
Entity Type:Organization
Organization Name:WOMENS HEALTHCARE PAVILLION PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANT
Authorized Official - Middle Name:K
Authorized Official - Last Name:NISCHAL
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:732-707-3545
Mailing Address - Street 1:200 PERRINE RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-2842
Mailing Address - Country:US
Mailing Address - Phone:732-707-3545
Mailing Address - Fax:732-707-3546
Practice Address - Street 1:200 PERRINE RD
Practice Address - Street 2:SUITE 204
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-2842
Practice Address - Country:US
Practice Address - Phone:732-707-3545
Practice Address - Fax:732-707-3546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00118500305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS87690Medicare UPIN