=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457080178
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PLATINUM PROVIDERS GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2022
-----------------------------------------------------
Last Update Date | 07/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1418 NEW RD STE 1
-----------------------------------------------------
City | NORTHFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08225-1179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-796-7969
-----------------------------------------------------
Fax | 609-642-2663
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2106 NEW RD STE F2
-----------------------------------------------------
City | LINWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08221-1053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-796-7969
-----------------------------------------------------
Fax | 609-642-2663
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | ATHANASIOS G. PAPASTAMELOS
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 609-469-1585
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------