Healthcare Provider Details

I. General information

NPI: 1255307989
Provider Name (Legal Business Name): LAURENCE M. MILGRIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 05/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 RUCKMAN RD
CLOSTER NJ
07624-2100
US

IV. Provider business mailing address

PO BOX 419430
BOSTON MA
02241-9430
US

V. Phone/Fax

Practice location:
  • Phone: 201-385-6161
  • Fax: 201-385-1671
Mailing address:
  • Phone: 201-967-8221
  • Fax: 201-483-2242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number25MA08378800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: