Healthcare Provider Details

I. General information

NPI: 1619978905
Provider Name (Legal Business Name): EDWARD R PRINS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 11/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 SUMMIT AVE
HACKENSACK NJ
07601
US

IV. Provider business mailing address

5 SUMMIT AVE
HACKENSACK NJ
07601
US

V. Phone/Fax

Practice location:
  • Phone: 201-646-0001
  • Fax: 201-646-9101
Mailing address:
  • Phone: 201-646-0001
  • Fax: 201-646-9101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMA042916
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0004213156
Identifier TypeOTHER
Identifier State
Identifier IssuerAETNA US HEALTHCARE
# 2
Identifier110131307
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE
# 3
Identifier0109911000
Identifier TypeOTHER
Identifier State
Identifier IssuerAMERIHEALTH
# 4
IdentifierBP105
Identifier TypeOTHER
Identifier State
Identifier IssuerOXFORD HEALTH PLANS
# 5
Identifier527245
Identifier TypeOTHER
Identifier State
Identifier IssuerMEDICARE GROUP PROVIDER
# 6
Identifier80631
Identifier TypeOTHER
Identifier State
Identifier IssuerAMERIGROUP

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: