Healthcare Provider Details

I. General information

NPI: 1730245333
Provider Name (Legal Business Name): PHYLLIS SHETTY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 GAITHER DR
MOUNT LAUREL NJ
08054-1715
US

IV. Provider business mailing address

700 US RT 130 N SUITE 203
CINNAMINSON NJ
08077
US

V. Phone/Fax

Practice location:
  • Phone: 856-722-7000
  • Fax: 856-829-0580
Mailing address:
  • Phone: 856-829-9345
  • Fax: 856-829-0580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA03821300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: