Healthcare Provider Details

I. General information

NPI: 1467448514
Provider Name (Legal Business Name): AMY ILYSE FREEMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY ILYSE KRUPNICK MD

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 02/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 E WILLOW ST
MILLBURN NJ
07041-1417
US

IV. Provider business mailing address

12 EAST WILLOW STREET
MILLBURN NJ
07041
US

V. Phone/Fax

Practice location:
  • Phone: 973-376-8500
  • Fax: 973-376-1820
Mailing address:
  • Phone: 973-376-8500
  • Fax: 973-376-1820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME 92169
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number25MA08081300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: