Healthcare Provider Details

I. General information

NPI: 1619115086
Provider Name (Legal Business Name): RUTGERS, THE STATE UNIVERSITY OF NEW JERSEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2009
Last Update Date: 01/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 BISHOP PL
NEW BRUNSWICK NJ
08901-1178
US

IV. Provider business mailing address

PO BOX 5199
ABILENE TX
79608-5199
US

V. Phone/Fax

Practice location:
  • Phone: 732-932-7402
  • Fax: 732-932-8255
Mailing address:
  • Phone: 325-437-8300
  • Fax: 325-437-8390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA07568400
License Number StateNJ

VIII. Authorized Official

Name: MELODEE LASKY
Title or Position: EXECUTIVE DIRECTOR
Credential: MD
Phone: 732-932-7402