=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033309968
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVINE GRACE MEDICAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2007
-----------------------------------------------------
Last Update Date | 07/26/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 159 BLOOMFIELD AVE
-----------------------------------------------------
City | NUTLEY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07110-3135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-235-1772
-----------------------------------------------------
Fax | 973-235-1774
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 159 BLOOMFIELD AVE
-----------------------------------------------------
City | NUTLEY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07110-3135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-235-1772
-----------------------------------------------------
Fax | 973-235-1774
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | MARCIANO FIGUEROA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-235-1772
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------