Provider Demographics
NPI:1568417210
Name:POMPTON LAKES PULMONARY, P.C.
Entity Type:Organization
Organization Name:POMPTON LAKES PULMONARY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:O'DONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-694-1300
Mailing Address - Street 1:63 BEAVERBROOK RD STE 301
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07035-1440
Mailing Address - Country:US
Mailing Address - Phone:973-694-1300
Mailing Address - Fax:973-694-1399
Practice Address - Street 1:63 BEAVERBROOK RD STE 301
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:NJ
Practice Address - Zip Code:07035-1440
Practice Address - Country:US
Practice Address - Phone:973-694-1300
Practice Address - Fax:973-694-1399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6836101Medicaid
NJ=========OtherHORIZON BC/BS
NJ821251Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER