Provider Demographics
NPI:1366471351
Name:EDISON PODIATRY, PA
Entity Type:Organization
Organization Name:EDISON PODIATRY, PA
Other - Org Name:ROCHE PODIATRY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:908-753-0500
Mailing Address - Street 1:4 PROGRESS ST
Mailing Address - Street 2:STE B5
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-1199
Mailing Address - Country:US
Mailing Address - Phone:908-753-0500
Mailing Address - Fax:908-753-0199
Practice Address - Street 1:4 PROGRESS ST
Practice Address - Street 2:STE B5
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-1199
Practice Address - Country:US
Practice Address - Phone:908-753-0500
Practice Address - Fax:908-753-0199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1112370001Medicare NSC
NJ021592Medicare ID - Type UnspecifiedMEDICARE