Provider Demographics
NPI:1114149705
Name:MED PRACTICE LLC
Entity Type:Organization
Organization Name:MED PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RENUKAMBA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUBBI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-823-7373
Mailing Address - Street 1:12 BERNART CT
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NJ
Mailing Address - Zip Code:08844-8703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 BERNART CT
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NJ
Practice Address - Zip Code:08844-8703
Practice Address - Country:US
Practice Address - Phone:732-823-7373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA084978282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care HospitalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ207RG0300XMedicare UPIN