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 | 174400000X | Specialist | | 25MA03846900 | 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 | 0K7075 | OTHER | NEW JERSEY | HEALTHNET ID # |
| 2 | 10988 | OTHER | NEW JERSEY | AMERIGROUP / AMERICAID ID |
| 3 | EP177 | OTHER | NEW JERSEY | OXFORD ID # |
| 4 | 8283303 | MEDICAID | NEW JERSEY | |
| 5 | 2489503 | MEDICAID | NEW JERSEY | |
| 6 | 4093998 | OTHER | NEW JERSEY | AETNA PPO ID # |
| 7 | 538131 | MEDICARE ID-TYPE UNSPECIFIED | NEW JERSEY | MEDICARE ID # |
| 8 | 0056541 | OTHER | NEW JERSEY | GHI PPO ID # |
| 9 | 47A221 | OTHER | NEW JERSEY | EMPIRE BC/BS OF NY ID # |
| 10 | 0041953 | OTHER | NEW JERSEY | AETNA HMO ID # |
| 11 | 0791898000 | OTHER | NEW JERSEY | AMERIHEALTH ID # |
| 12 | 1009105 | OTHER | NEW JERSEY | HORIZON MERCY ID # |
| 13 | F13858 | MEDICARE UPIN | NEW JERSEY | |
