Provider Demographics
NPI:1568531432
Name:IMBORNONE, PETER JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOSEPH
Last Name:IMBORNONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 PARKWAY
Mailing Address - Street 2:ROCHELLE PARK MEDICAL CENTER PA
Mailing Address - City:ROCHELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07662
Mailing Address - Country:US
Mailing Address - Phone:201-291-1010
Mailing Address - Fax:201-587-0313
Practice Address - Street 1:96 PARKWAY
Practice Address - Street 2:ROCHELLE PARK MEDICAL CENTER PA
Practice Address - City:ROCHELLE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07662
Practice Address - Country:US
Practice Address - Phone:201-291-1010
Practice Address - Fax:201-587-0313
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04117600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1568531432OtherNPI
IM451314Medicare ID - Type Unspecified
C55188Medicare UPIN
NJC55188Medicare UPIN