Healthcare Provider Details

I. General information

NPI: 1760719793
Provider Name (Legal Business Name): PROSPECT WOMEN'S MEDICAL GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2009
Last Update Date: 11/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 PROSPECT AVE
HACKENSACK NJ
07601-2256
US

IV. Provider business mailing address

120 PROSPECT AVE
HACKENSACK NJ
07601-2256
US

V. Phone/Fax

Practice location:
  • Phone: 201-342-1600
  • Fax: 201-342-2280
Mailing address:
  • Phone: 201-342-1600
  • Fax: 201-342-2280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number25MA05630700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MA05630700
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MA05630700
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name: ROBIN H. LEVAT
Title or Position: PRESIDENT
Credential: MD
Phone: 201-342-1600