Provider Demographics
NPI:1740247964
Name:TRENTON FAMILY PRACTICE P.C.
Entity type:Organization
Organization Name:TRENTON FAMILY PRACTICE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:M
Authorized Official - Last Name:REGIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-272-0655
Mailing Address - Street 1:22 NORTH FRANKLIN AVENUE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08232
Mailing Address - Country:US
Mailing Address - Phone:609-272-0655
Mailing Address - Fax:609-272-9317
Practice Address - Street 1:725 WEST STATESTREET
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08618
Practice Address - Country:US
Practice Address - Phone:609-392-2585
Practice Address - Fax:609-392-1448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA59582174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5569702Medicaid
NJ6416802Medicaid
NJ170632Medicare PIN
NJ6416802Medicaid