Provider Demographics
NPI:1972678977
Name:MODERN NEPHROLOGY & TRANSPLANT, LLC
Entity Type:Organization
Organization Name:MODERN NEPHROLOGY & TRANSPLANT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MS
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BONOMINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-419-0417
Mailing Address - Street 1:767 NORTHFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1194
Mailing Address - Country:US
Mailing Address - Phone:973-419-0417
Mailing Address - Fax:862-766-5904
Practice Address - Street 1:767 NORTHFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1194
Practice Address - Country:US
Practice Address - Phone:973-419-0417
Practice Address - Fax:862-766-5904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ083828Medicare ID - Type Unspecified