Healthcare Provider Details

I. General information

NPI: 1992057095
Provider Name (Legal Business Name): ANNA SHOSHILOS, D.O, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2012
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

784 CHIMNEY ROCK RD SUITE: G
MARTINSVILLE NJ
08836-2272
US

IV. Provider business mailing address

96 LINWOOD PLZ SUITE NUMBER: 347
FORT LEE NJ
07024-3701
US

V. Phone/Fax

Practice location:
  • Phone: 732-271-1771
  • Fax: 732-271-9477
Mailing address:
  • Phone: 973-699-9765
  • Fax: 347-474-7300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MB06906000
License Number StateNJ

VIII. Authorized Official

Name: DR. ANNA SHOSHILOS
Title or Position: OWNER
Credential: D.O
Phone: 973-699-6765