=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063280634
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 525 MEDICAL GROUP OF NEW JERSEY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2023
-----------------------------------------------------
Last Update Date | 12/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 245 5TH AVE FL 3
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-8728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-276-2061
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 245 5TH AVE FL 3
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-8728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | RAQUEL RODRIGUEZ MARTINEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 929-276-2061
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------