Healthcare Provider Details

I. General information

NPI: 1801888995
Provider Name (Legal Business Name): PAUL S. PANEBIANCO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 JOHNSON RD SUITE 4
TURNERSVILLE NJ
08012-1777
US

IV. Provider business mailing address

129 JOHNSON RD SUITE 4
TURNERSVILLE NJ
08012-1777
US

V. Phone/Fax

Practice location:
  • Phone: 856-374-4440
  • Fax: 856-374-4445
Mailing address:
  • Phone: 856-374-4440
  • Fax: 856-374-4445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMB03115000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberOS003416L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: