=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275879215
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT L WELLNER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2012
-----------------------------------------------------
Last Update Date | 01/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 FORRESTAL RD S SUITE 209
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08540-6666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-720-0032
-----------------------------------------------------
Fax | 609-720-0034
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 FORRESTAL RD S SUITE 209
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08540-6666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-720-0032
-----------------------------------------------------
Fax | 609-720-0034
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ROBERT L WELLNER
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 609-358-1788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 25MB07771400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------