MEDICARE: DR. COLIN A, PEMBERTON M.D.

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	207R00000X	Internal Medicine Physician	025MA08530400	NJ
2	261QP2300X	Primary Care Clinic/Center	025MA08530400	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891935557
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. COLIN A, PEMBERTON M.D.

Provider Business Mailing Address
First Line	:	2 DEVONSHIRE TER
Second Line	:
City	:	WEST ORANGE
State	:	NJ
Zip	:	07052-2708
Country	:	US
Telephone Number	:	973-444-0983
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 ORANGE ST
Second Line	:	SUITE 1
City	:	NEWARK
State	:	NJ
Zip	:	07107-2944
Country	:	US
Telephone Number	:	973-842-8398
Fax Number	:

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

Provider Enumeration Date	:	02/20/2009
Last Update Date	:	03/18/2015

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