Healthcare Provider Details

I. General information

NPI: 1891706842
Provider Name (Legal Business Name): HILLSIDE FAMILY PRACTICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 02/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOLLYWOOD AVE HILLSIDE FAMILY PRACTICE
HILLSIDE NJ
07205-2409
US

IV. Provider business mailing address

100 HOLLYWOOD AVE HILLSIDE FAMILY PRACTICE
HILLSIDE NJ
07205-2409
US

V. Phone/Fax

Practice location:
  • Phone: 908-353-7949
  • Fax: 908-353-8374
Mailing address:
  • Phone: 908-353-7949
  • Fax: 908-353-8374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB02410900
License Number StateNJ

VIII. Authorized Official

Name: WALTER MATKIWSKY
Title or Position: PRESIDENT
Credential: DO
Phone: 908-353-7949