MEDICARE: CARLSON MEDICAL LLC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1346787256
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARLSON MEDICAL LLC

Provider Business Mailing Address
First Line	:	385 S MAPLE AVE STE 101
Second Line	:
City	:	GLEN ROCK
State	:	NJ
Zip	:	07452-1545
Country	:	US
Telephone Number	:	201-345-1855
Fax Number	:

Provider Business Practice Location Address
First Line	:	385 S MAPLE AVE STE 101
Second Line	:
City	:	GLEN ROCK
State	:	NJ
Zip	:	07452-1545
Country	:	US
Telephone Number	:	201-345-1855
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SANDRA CARLSON
Credential	:	MD
Telephone Number	:	201-345-1855

Provider Enumeration Date	:	01/30/2017
Last Update Date	:	02/27/2017

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