Healthcare Provider Details

I. General information

NPI: 1649357435
Provider Name (Legal Business Name): NORTHERN JERSEY PLASTIC SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 ROCKWOOD PL STE 405
ENGLEWOOD NJ
07631-4960
US

IV. Provider business mailing address

25 ROCKWOOD PL STE 405
ENGLEWOOD NJ
07631-4960
US

V. Phone/Fax

Practice location:
  • Phone: 201-225-1811
  • Fax: 201-616-7789
Mailing address:
  • Phone: 201-225-1811
  • Fax: 201-616-7789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number25MA08118000
License Number StateNJ

VIII. Authorized Official

Name: DR. TROY EZRA CALLAHAN
Title or Position: MANAGING DIRECTOR
Credential: M.D.
Phone: 201-225-1811