Healthcare Provider Details

I. General information

NPI: 1407188923
Provider Name (Legal Business Name): PREMIUM FAMILY HEALTH CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2010
Last Update Date: 02/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 CHRISTOPHER COLUMBUS DR SUITE 300
JERSEY CITY NJ
07302-5526
US

IV. Provider business mailing address

115 CHRISTOPHER COLUMBUS DR SUITE 300
JERSEY CITY NJ
07302-5526
US

V. Phone/Fax

Practice location:
  • Phone: 201-547-3555
  • Fax: 201-547-8259
Mailing address:
  • Phone: 201-547-3555
  • Fax: 201-547-8259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMA071041
License Number StateNJ

VIII. Authorized Official

Name: MS. CAROL CHRISTINE SKIPPER
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 201-547-3555