Healthcare Provider Details

I. General information

NPI: 1851959225
Provider Name (Legal Business Name): CMD NJ PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 05/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 N DEAN ST
ENGLEWOOD NJ
07631-2533
US

IV. Provider business mailing address

177 N DEAN ST
ENGLEWOOD NJ
07631-2533
US

V. Phone/Fax

Practice location:
  • Phone: 201-510-3777
  • Fax: 201-501-3778
Mailing address:
  • Phone: 201-510-3777
  • Fax: 201-501-3778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY LEGG
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 347-584-8903