Healthcare Provider Details

I. General information

NPI: 1063586485
Provider Name (Legal Business Name): STEPHEN PERCY JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE HACKENSACK UNIVERSITY MEDICAL CENTER
HACKENSACK NJ
07601-1914
US

IV. Provider business mailing address

30 PROSPECT AVE HACKENSACK UNIVERSITY MEDICAL CENTER
HACKENSACK NJ
07601-1914
US

V. Phone/Fax

Practice location:
  • Phone: 201-996-5201
  • Fax: 201-996-0754
Mailing address:
  • Phone: 201-996-5201
  • Fax: 201-996-0754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number25MA05674700
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier7718403
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: