Healthcare Provider Details

I. General information

NPI: 1871940916
Provider Name (Legal Business Name): PREM MONITA ADIP MBBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96799 TURNER DRIVE
PAGO PAGO AS
96799-9994
US

IV. Provider business mailing address

PO BOX LBJ
PAGO PAGO AS
96799-9994
US

V. Phone/Fax

Practice location:
  • Phone: 684-633-1222
  • Fax: 684-633-2893
Mailing address:
  • Phone: 684-633-1222
  • Fax: 684-633-2893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4042-C
License Number StateAS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: