Healthcare Provider Details

I. General information

NPI: 1679541569
Provider Name (Legal Business Name): ROLYCITO A CHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 08/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 ENGLE ST 2ND FLOOR, ANESTHESIA DEPT
ENGLEWOOD NJ
07631-1808
US

IV. Provider business mailing address

375 ENGLE ST SECOND FLOOR
ENGLEWOOD NJ
07631-1823
US

V. Phone/Fax

Practice location:
  • Phone: 201-894-3322
  • Fax: 201-894-0585
Mailing address:
  • Phone: 201-871-6073
  • Fax: 201-655-6159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA03602400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: