Provider Demographics
NPI:1265014583
Name:PREGMUNE MEDICAL PA
Entity type:Organization
Organization Name:PREGMUNE MEDICAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:MD
Authorized Official - Last Name:VIDALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-584-8710
Mailing Address - Street 1:344 GROVE STREET
Mailing Address - Street 2:PMB 60570
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302
Mailing Address - Country:US
Mailing Address - Phone:516-584-8710
Mailing Address - Fax:516-584-8711
Practice Address - Street 1:308 WILLOW AVE
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-3808
Practice Address - Country:US
Practice Address - Phone:516-584-8710
Practice Address - Fax:516-584-8711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-26
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Single Specialty