Healthcare Provider Details

I. General information

NPI: 1871890079
Provider Name (Legal Business Name): EWR MEDPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2011
Last Update Date: 02/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 BREWSTER RD STE 201
NEWARK NJ
07114
US

IV. Provider business mailing address

339 BREWSTER RD STE 201
NEWARK NJ
07114
US

V. Phone/Fax

Practice location:
  • Phone: 973-877-0991
  • Fax:
Mailing address:
  • Phone: 973-877-0991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number25MA08091000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number38MC00672500
License Number StateNJ

VIII. Authorized Official

Name: DR. JEFFREY WITZ
Title or Position: DIRECTOR
Credential: DC
Phone: 973-877-0991