Provider Demographics
NPI:1659306769
Name:WATER STREET PHYSICIANS LLC
Entity Type:Organization
Organization Name:WATER STREET PHYSICIANS LLC
Other - Org Name:LIMITED LIABILITY CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PINO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:732-349-4030
Mailing Address - Street 1:300 W WATER ST
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-6533
Mailing Address - Country:US
Mailing Address - Phone:732-349-4030
Mailing Address - Fax:732-244-1866
Practice Address - Street 1:300 W WATER ST
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-6533
Practice Address - Country:US
Practice Address - Phone:732-349-4030
Practice Address - Fax:732-244-1866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE06158Medicare UPIN