MEDICARE: DR. RONALD KEITH WILLENBORG M.D.

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	207R00000X	Internal Medicine Physician	25MA03592100	NJ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
9	110009806	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P3601332	OTHER	NJ	OXFORD HEALTH
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0004574647	OTHER	NJ	AETNA
4	001130735	OTHER	NJ	UNITED HEALTHCARE
5	31D08	OTHER	NY	EMPIRE BLUE SHIELD
6	OK0464	OTHER	NJ	HEALTH NET
7	8971366	OTHER	NJ	CIGNA
8	NJ3106	OTHER	NJ	FIRST HEALTH
10	J2407	OTHER	NJ	HORIZON BLUE CROSS/SHIELD

General Provider Information

NPI Number	:	1801897897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RONALD KEITH WILLENBORG M.D.

Provider Business Mailing Address
First Line	:	543 VALLEY RD STE 4
Second Line	:
City	:	UPPER MONTCLAIR
State	:	NJ
Zip	:	07043-1844
Country	:	US
Telephone Number	:	973-746-6466
Fax Number	:	973-746-0312

Provider Business Practice Location Address
First Line	:	543 VALLEY RD STE 4
Second Line	:
City	:	UPPER MONTCLAIR
State	:	NJ
Zip	:	07043-1844
Country	:	US
Telephone Number	:	973-746-6466
Fax Number	:	973-746-0312

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	07/14/2010

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