Healthcare Provider Details

I. General information

NPI: 1922168533
Provider Name (Legal Business Name): FUNCTIONAL DIAGNOSTICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

364 BROAD ST
KEYPORT NJ
07735-1619
US

IV. Provider business mailing address

364 BROAD ST
KEYPORT NJ
07735-1619
US

V. Phone/Fax

Practice location:
  • Phone: 732-335-4040
  • Fax: 732-335-0516
Mailing address:
  • Phone: 732-335-4040
  • Fax: 732-335-0516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL CHILLEMI
Title or Position: CEO
Credential:
Phone: 732-335-4040