MEDICARE: JACQUES CAROL RAYMOND 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	174400000X	Specialist	25MAO7123300	NJ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00624016	OTHER	NJ	MEDICARE RAILROAD CARRIER

General Provider Information

NPI Number	:	1407855984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUES CAROL RAYMOND MD

Provider Business Mailing Address
First Line	:	294 CENTRAL AVE
Second Line	:	FL 1
City	:	ORANGE
State	:	NJ
Zip	:	07050-3414
Country	:	US
Telephone Number	:	973-676-6556
Fax Number	:	973-676-6543

Provider Business Practice Location Address
First Line	:	294 CENTRAL AVE
Second Line	:	FL 1
City	:	ORANGE
State	:	NJ
Zip	:	07050-3414
Country	:	US
Telephone Number	:	973-676-6556
Fax Number	:	973-676-6543

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

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	09/21/2018

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