Healthcare Provider Details

I. General information

NPI: 1124071535
Provider Name (Legal Business Name): MARY JOSSELYN BLISS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: MOLLY BLISS

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1914
US

IV. Provider business mailing address

PO BOX 169
GLADSTONE NJ
07934-0169
US

V. Phone/Fax

Practice location:
  • Phone: 201-996-2000
  • Fax:
Mailing address:
  • Phone: 908-470-9624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License Number25MA07950300
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: