=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629264783
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REGIONAL PSYCHIATRIC GROUP, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2007
-----------------------------------------------------
Last Update Date | 10/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 144 TAMARACK CIR
-----------------------------------------------------
City | SKILLMAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08558-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-921-7382
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1330 ROUTE 206
-----------------------------------------------------
City | SKILLMAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08558-1921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-921-7382
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOSE S VAZQUEZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 609-921-7382
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MA43184
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------