Healthcare Provider Details

I. General information

NPI: 1053368837
Provider Name (Legal Business Name): LAKELAND CARDIOLOGY CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 BOULEVARD
MOUNTAIN LAKES NJ
07046-1723
US

IV. Provider business mailing address

415 BOULEVARD
MOUNTAIN LAKES NJ
07046-1723
US

V. Phone/Fax

Practice location:
  • Phone: 973-334-7700
  • Fax: 973-263-5225
Mailing address:
  • Phone: 973-334-7700
  • Fax: 973-263-5225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number207RC0000X
License Number StateNJ

VIII. Authorized Official

Name: ROBERT M. WALL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 973-334-7700