Healthcare Provider Details

I. General information

NPI: 1942226287
Provider Name (Legal Business Name): TARA ANNE MATTHEWS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 NEW PROVIDENCE RD CHILDREN'S SPECIALIZED HOSPITAL
MOUNTAINSIDE NJ
07092-2590
US

IV. Provider business mailing address

815 MOUNTAIN AVE APT C19
SPRINGFIELD NJ
07081-3446
US

V. Phone/Fax

Practice location:
  • Phone: 908-301-5491
  • Fax: 908-301-5408
Mailing address:
  • Phone: 973-467-0625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA07594100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: