Healthcare Provider Details

I. General information

NPI: 1972044923
Provider Name (Legal Business Name): MEDICAL SERVICE PROFESSIONALS OF NJ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2017
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 CHUBB AVE SUITE 100-S
LYNDHURST NJ
07071-3504
US

IV. Provider business mailing address

125 CHUBB AVE STE 100S
LYNDHURST NJ
07071-3504
US

V. Phone/Fax

Practice location:
  • Phone: 201-559-7600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KELLY FONTANA
Title or Position: DIRECTOR OF CLINICAL COMPLIANCE
Credential:
Phone: 631-457-9145