MEDICARE: EUMENA DIVINO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	25MA02674500	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1108112	OTHER	NJ	AETNA HMO #
2	P3618222	OTHER	NJ	OXFORD #
3	2K9373	OTHER	NJ	HEALTHNET #
4	805E92	OTHER	NJ	EMPIRE BCBS (FORDS)
5	0102820000	OTHER	NJ	AMERIHEALTH #
6	0296220	OTHER	NJ	GHI PPO #
7	4272415	OTHER	NJ	AETNA PPO #
8	805E91	OTHER	NJ	EMPIRE BCBS (PERTH AMBOY)

General Provider Information

NPI Number	:	1225076235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EUMENA DIVINO

Provider Business Mailing Address
First Line	:	PO BOX 48270
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07101-4800
Country	:	US
Telephone Number	:	201-818-9118
Fax Number	:

Provider Business Practice Location Address
First Line	:	390 NEW BRUNSWICK AVE
Second Line	:
City	:	FORDS
State	:	NJ
Zip	:	08863-2110
Country	:	US
Telephone Number	:	732-738-4260
Fax Number	:	732-738-5693

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	04/16/2008

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Directions to “ EUMENA DIVINO ” Practice Location

Language	Start Address	Practice Location

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