Provider Demographics
NPI:1558546630
Name:POBLETE MEDICAL PRACTICE, PC
Entity Type:Organization
Organization Name:POBLETE MEDICAL PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:POBLETE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-253-7800
Mailing Address - Street 1:519 RIVER DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:GARFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07026-3219
Mailing Address - Country:US
Mailing Address - Phone:973-253-7800
Mailing Address - Fax:973-253-8503
Practice Address - Street 1:519 RIVER DR
Practice Address - Street 2:SUITE 4
Practice Address - City:GARFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07026-3219
Practice Address - Country:US
Practice Address - Phone:973-253-7800
Practice Address - Fax:973-253-8503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4645405Medicaid
NJ122932Medicare PIN