Healthcare Provider Details

I. General information

NPI: 1184643132
Provider Name (Legal Business Name): MEDEMERGE P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 01/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 N. WASHINGTON AVE
GREEN BROOK NJ
08812-2619
US

IV. Provider business mailing address

PO BOX 890
GREEN BROOK NJ
08812-2619
US

V. Phone/Fax

Practice location:
  • Phone: 732-968-8900
  • Fax: 732-968-4898
Mailing address:
  • Phone: 732-968-8900
  • Fax: 732-968-4898

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: JOHN D. PILLA
Title or Position: DIRECTOR
Credential: MD
Phone: 732-968-8900