Healthcare Provider Details

I. General information

NPI: 1588693915
Provider Name (Legal Business Name): ROBERT EMMIT WARD ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 FOWNES AVE
BRIGANTINE NJ
08203-3033
US

IV. Provider business mailing address

806 FOWNES AVE
BRIGANTINE NJ
08203-3033
US

V. Phone/Fax

Practice location:
  • Phone: 610-216-9466
  • Fax:
Mailing address:
  • Phone: 610-216-9466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number25MT00254600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: