Healthcare Provider Details

I. General information

NPI: 1487770905
Provider Name (Legal Business Name): ASSOCIATES IN DERMATOLOGY AND COSMETIC SURGERY THE MILLBURN LASER CENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
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
07041-1737
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 TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMC68842
License Number StateNJ

VIII. Authorized Official

Name: ERIC SCOTT SIEGEL
Title or Position: OWNER
Credential: MD
Phone: 973-376-8500