Provider Demographics
NPI:1013485226
Name:NORTHERN VALLEY ID, PC
Entity Type:Organization
Organization Name:NORTHERN VALLEY ID, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-408-5314
Mailing Address - Street 1:400 SYLVAN AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD CLIFFS
Mailing Address - State:NJ
Mailing Address - Zip Code:07632-2717
Mailing Address - Country:US
Mailing Address - Phone:201-408-5314
Mailing Address - Fax:
Practice Address - Street 1:400 SYLVAN AVE STE 108
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-2717
Practice Address - Country:US
Practice Address - Phone:201-408-5314
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty