Healthcare Provider Details

I. General information

NPI: 1225034887
Provider Name (Legal Business Name): SAMUEL CARUTHERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 12/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 MAIN ST STE 101D
BOONTON NJ
07005-1799
US

IV. Provider business mailing address

P.O. BOX 429
MOUNTAIN LAKES NJ
07046-1119
US

V. Phone/Fax

Practice location:
  • Phone: 862-222-4629
  • Fax: 973-352-9519
Mailing address:
  • Phone: 862-222-4629
  • Fax: 973-352-9519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number217213
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number25MA07863200
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number217213
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA07863200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: