Healthcare Provider Details

I. General information

NPI: 1770575821
Provider Name (Legal Business Name): ROGER LALLEMAND JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 ROUTE 516
OLD BRIDGE NJ
08857-1416
US

IV. Provider business mailing address

59 ROUTE 516
OLD BRIDGE NJ
08857-1416
US

V. Phone/Fax

Practice location:
  • Phone: 732-613-1000
  • Fax: 732-613-1092
Mailing address:
  • Phone: 732-613-1000
  • Fax: 732-613-1092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number25MA07185000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MA07185000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: