1063748747 NPI number — ANN UNIVERSITY PEDIATRICS, LLC

Table of content: (NPI 1063748747)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063748747 NPI number — ANN UNIVERSITY PEDIATRICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANN UNIVERSITY PEDIATRICS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ANNIE H. LI, MD
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063748747
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1259 RT 46 EAST, TROY OFFICE CENTER
Provider Second Line Business Mailing Address:
SUITE 101, BUILDING 4C
Provider Business Mailing Address City Name:
PARSIPPANY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
873-257-8870
Provider Business Mailing Address Fax Number:
973-257-8871

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1259 RT 46 EAST, TROY OFFICE CENTER
Provider Second Line Business Practice Location Address:
SUITE 101, BUILDING 4C
Provider Business Practice Location Address City Name:
PARSIPPANY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
873-257-8870
Provider Business Practice Location Address Fax Number:
973-257-8871
Provider Enumeration Date:
10/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LI
Authorized Official First Name:
ANNIE
Authorized Official Middle Name:
HONGYAN
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
973-257-8870

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MA071077 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8582301 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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