Healthcare Provider Details

I. General information

NPI: 1952615247
Provider Name (Legal Business Name): ELLEN LEVAN, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 BRANFORD PL
NEWARK NJ
07102-2711
US

IV. Provider business mailing address

23 BRANFORD PL
NEWARK NJ
07102-2711
US

V. Phone/Fax

Practice location:
  • Phone: 973-424-0080
  • Fax: 973-424-0088
Mailing address:
  • Phone: 973-424-0080
  • Fax: 973-424-0088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP00016700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number26NP05605400
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA04281900
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA07184800
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number25MA05569500
License Number StateNJ

VIII. Authorized Official

Name: DR. ELLEN LEVAN
Title or Position: PHYSICIAN
Credential: MD
Phone: 973-424-0080