Healthcare Provider Details

I. General information

NPI: 1891905873
Provider Name (Legal Business Name): MEDICAL MULTISPECIALTY ASSOCIATION PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11-26 SADDLE RIVER RD
FAIR LAWN NJ
07410-5634
US

IV. Provider business mailing address

11-26 SADDLE RIVER RD
FAIR LAWN NJ
07410-5634
US

V. Phone/Fax

Practice location:
  • Phone: 201-796-9200
  • Fax: 201-796-7606
Mailing address:
  • Phone: 201-796-9200
  • Fax: 201-796-7606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number25MD00298000
License Number StateNJ
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP001995
License Number StateNJ

VIII. Authorized Official

Name: DR. BRAD HERMAN
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 201-796-9200