Healthcare Provider Details

I. General information

NPI: 1184759458
Provider Name (Legal Business Name): UMDNJ RWJ PEDIATRIC UROLOGY SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 PATERSON ST SUITE 4100
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: 732-235-7776
  • Fax:
Mailing address:
  • Phone: 732-212-0051
  • Fax: 732-212-0713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number State

VIII. Authorized Official

Name: AMY KLUGEWICZ
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 732-212-0051