=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740405075
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALFREDO FESTA M.D.P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2007
-----------------------------------------------------
Last Update Date | 12/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4508 KENNEDY BLVD
-----------------------------------------------------
City | UNION CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07087-2707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-864-3168
-----------------------------------------------------
Fax | 201-864-4488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2475
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07015-2475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-864-3168
-----------------------------------------------------
Fax | 201-864-4488
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ALFREDO FESTA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 201-864-3168
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 25MA03916500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------