Healthcare Provider Details

I. General information

NPI: 1104908813
Provider Name (Legal Business Name): CLIFFSIDE MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

663 PALISADE AVE
CLIFFSIDE PARK NJ
07010-3012
US

IV. Provider business mailing address

663 PALISADE AVE STE 101
CLIFFSIDE PARK NJ
07010-3098
US

V. Phone/Fax

Practice location:
  • Phone: 201-945-6500
  • Fax: 201-945-1157
Mailing address:
  • Phone: 201-945-6500
  • Fax: 201-945-1157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN S CHOUAKE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 201-945-6500