Healthcare Provider Details

I. General information

NPI: 1043704810
Provider Name (Legal Business Name): FAMILY LEGACY MEDICAL CARE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2018
Last Update Date: 01/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 JEFFERSON AVE
ELIZABETH NJ
07201-2417
US

IV. Provider business mailing address

115 JEFFERSON AVE
ELIZABETH NJ
07201-2417
US

V. Phone/Fax

Practice location:
  • Phone: 908-351-6663
  • Fax: 908-351-1760
Mailing address:
  • Phone: 908-351-6663
  • Fax: 908-351-1760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PASCALE FERDINAND
Title or Position: PHYSICIAN
Credential: MD
Phone: 908-351-6663