Basic Information
| Provider Information | |||||||||
| NPI: | 1003142746 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ONGSUCO | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | TSAREVICH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LIBO-ON | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | TSAREVICH | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4 WELDON RD | ||||||||
| Address2: | |||||||||
| City: | EDISON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088173724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6462670502 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4 WELDON RD | ||||||||
| Address2: | |||||||||
| City: | EDISON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088173724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6462670502 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2009 | ||||||||
| LastUpdateDate: | 05/07/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01077600 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.