Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 2084N0400X | Psychiatry & Neurology | Neurology | MD045495M | PENNSYLVANIA | No |
| 2 | 2084N0400X | Psychiatry & Neurology | Neurology | 25MA06559700 | NEW JERSEY | No |
| 3 | 2084N0400X | Psychiatry & Neurology | Neurology | MD062295L | PENNSYLVANIA | No |
| 4 | 2084N0400X | Psychiatry & Neurology | Neurology | MD2500056788 | NEW JERSEY | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 3738422 | OTHER | | AETNA INDIV. PROV # |
| 2 | P61458 | OTHER | | AMERIHEALTH GROUP # |
| 3 | 2255911000 | OTHER | | KEYSTONE/AMERIHEALTH GROU |
| 4 | G54070 | MEDICARE UPIN | | |
| 5 | 089173 | MEDICARE ID-TYPE UNSPECIFIED | NEW JERSEY | PROVIDER'S LEGACY # |
| 6 | T1954659 | OTHER | PENNSYLVANIA | BCBS INDIV. PROV # |
| 7 | F61302 | MEDICARE UPIN | | |
| 8 | 33423367 | OTHER | | AETNA GROUP # |
| 9 | 076488 | MEDICARE PIN | PENNSYLVANIA | |
| 10 | 0437018000 | OTHER | | AMERIHEALTH PROVIDER # |
| 11 | 8547249 | OTHER | | CIGNA GROUP # |
| 12 | 1561458 | OTHER | PENNSYLVANIA | BCBS GROUP # |
| 13 | P00272121 | MEDICARE ID-TYPE UNSPECIFIED | | INDIV. PROVIDER'S # |
| 14 | DB5398 | MEDICARE ID-TYPE UNSPECIFIED | | RAILROAD MEDICARE GRP # |
| 15 | P00112647 | MEDICARE ID-TYPE UNSPECIFIED | | RAILROAD INDIV. PROV. # |
| 16 | 055653SGP | MEDICARE ID-TYPE UNSPECIFIED | PENNSYLVANIA | PROVIDER'S LEGACY # |
| 17 | 080112 | MEDICARE ID-TYPE UNSPECIFIED | NEW JERSEY | PROVIDER'S LEGACY # |
| 18 | P3245151 | OTHER | | OXFORD HEALTH GROUP # |
| 19 | ========= | OTHER | NEW JERSEY | BCBS GROUP # |
| 20 | 3410492 | OTHER | | AETNA INDIV. PROV. # |
