Healthcare Provider Details

I. General information

NPI: 1194732743
Provider Name (Legal Business Name): RUTGERS HEALTH-RWJ SCLERODERMA PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 PATERSON ST SUITE 4200
NEW BRUNSWICK NJ
08901-1962
US

IV. Provider business mailing address

66 W GILBERT ST
RED BANK NJ
07701
US

V. Phone/Fax

Practice location:
  • Phone: 732-235-6600
  • Fax: 732-235-6650
Mailing address:
  • Phone: 732-212-0051
  • Fax: 732-212-0713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number State

VIII. Authorized Official

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