Healthcare Provider Details

I. General information

NPI: 1407827496
Provider Name (Legal Business Name): MATTHEW J PETRIDES PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 CORLIES AVE
NEPTUNE CITY NJ
07753-4859
US

IV. Provider business mailing address

1945 STATE ROUTE 33
NEPTUNE NJ
07753-4859
US

V. Phone/Fax

Practice location:
  • Phone: 732-775-5500
  • Fax:
Mailing address:
  • Phone: 732-776-4618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00032400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: