Provider Demographics
NPI:1548848906
Name:MY HOME TELEMED LLC
Entity type:Organization
Organization Name:MY HOME TELEMED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:S
Authorized Official - Last Name:TRUMBAUER
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APN,BC
Authorized Official - Phone:609-432-5417
Mailing Address - Street 1:106 ANITA DR
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-7522
Mailing Address - Country:US
Mailing Address - Phone:609-432-5417
Mailing Address - Fax:609-788-8111
Practice Address - Street 1:1156 PIEDMONT RD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-4843
Practice Address - Country:US
Practice Address - Phone:609-432-5417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ60062926Medicaid