MEDICARE: S. B. & R. D. PONAMGI MD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	25MA03284500	NJ

General Provider Information

NPI Number	:	1366788713
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	S. B. & R. D. PONAMGI MD PA

Provider Business Mailing Address
First Line	:	1101 PALISADE AVE
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-6329
Country	:	US
Telephone Number	:	201-224-8831
Fax Number	:	201-224-9278

Provider Business Practice Location Address
First Line	:	1101 PALISADE AVE
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-6329
Country	:	US
Telephone Number	:	201-224-8831
Fax Number	:	201-224-9278

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	BEYGUM KHAN
Credential	:	BSN, CPC
Telephone Number	:	201-224-8831

Provider Enumeration Date	:	12/12/2012
Last Update Date	:	05/30/2013

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