Healthcare Provider Details

I. General information

NPI: 1629277520
Provider Name (Legal Business Name): RUTGERS HEALTH-RWJ SCLERODERMA PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 FRENCH STREET, SUITE 2360 CHILD HEALTH INSTITUTE OF NEW JERSEY
NEW BRUNSWICK NJ
08901
US

IV. Provider business mailing address

66 W GILBERT ST
TINTON FALLS NJ
07701-4947
US

V. Phone/Fax

Practice location:
  • Phone: 732-235-7541
  • Fax: 732-235-8127
Mailing address:
  • Phone: 732-212-0051
  • Fax: 732-212-0713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State

VIII. Authorized Official

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