Healthcare Provider Details

I. General information

NPI: 1215062005
Provider Name (Legal Business Name): RUTGERS HEALTH-RWJ SCLERODERMA PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 GEORGE ST 1ST FLOOR
NEW BRUNSWICK NJ
08901-2008
US

IV. Provider business mailing address

66 W GILBERT ST 2ND FLOOR
TINTON FALLS NJ
07701-4947
US

V. Phone/Fax

Practice location:
  • Phone: 732-235-8993
  • Fax: 732-246-7317
Mailing address:
  • Phone: 732-212-0051
  • Fax: 732-212-0713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BRENDA LAWRENCE
Title or Position: DIRECTOR OF REVENUE CYCLE
Credential:
Phone: 732-235-6070