Healthcare Provider Details

I. General information

NPI: 1114327186
Provider Name (Legal Business Name): SUPERIOR PHYSICAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2014
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 ORANGE RD
MONTCLAIR NJ
07042-4451
US

IV. Provider business mailing address

309 ORANGE RD
MONTCLAIR NJ
07042-4451
US

V. Phone/Fax

Practice location:
  • Phone: 973-783-3606
  • Fax: 973-839-3653
Mailing address:
  • Phone: 973-783-3606
  • Fax: 973-839-3653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM B HOLDER
Title or Position: PROVIDER/OWNER
Credential: MD
Phone: 973-839-1003