Provider Demographics
NPI:1497958326
Name:COLONIAL VILLAGE MEDICAL,P.C.
Entity Type:Organization
Organization Name:COLONIAL VILLAGE MEDICAL,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:LEDINH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-548-7887
Mailing Address - Street 1:PO BOX 2505
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08818-2505
Mailing Address - Country:US
Mailing Address - Phone:732-548-7887
Mailing Address - Fax:732-548-7660
Practice Address - Street 1:3 STATE ROUTE 27
Practice Address - Street 2:SUITE 106
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3963
Practice Address - Country:US
Practice Address - Phone:732-548-7887
Practice Address - Fax:732-548-7660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04182100261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD96761Medicare UPIN
NJ452482UTAMedicare ID - Type Unspecified