MEDICARE: DR. ALICIA RAQUEL DERMER MD

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	207Q00000X	Family Medicine Physician	MA40118	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316058852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALICIA RAQUEL DERMER MD

Provider Business Mailing Address
First Line	:	1001 W MAIN ST
Second Line	:	SUITE B
City	:	FREEHOLD
State	:	NJ
Zip	:	07728-2579
Country	:	US
Telephone Number	:	732-294-2540
Fax Number	:	732-294-9328

Provider Business Practice Location Address
First Line	:	1001 W MAIN ST
Second Line	:	SUITE B
City	:	FREEHOLD
State	:	NJ
Zip	:	07728-2579
Country	:	US
Telephone Number	:	732-294-2540
Fax Number	:	732-294-9328

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	05/09/2011

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