Healthcare Provider Details

I. General information

NPI: 1124543095
Provider Name (Legal Business Name): CCMMA NJ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2017
Last Update Date: 10/14/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 BOULEVARD
PASSAIC NJ
07055-2840
US

IV. Provider business mailing address

PO BOX 631800
CINCINNATI OH
45263-1800
US

V. Phone/Fax

Practice location:
  • Phone: 973-365-4300
  • Fax:
Mailing address:
  • Phone: 845-702-2711
  • Fax: 888-220-6560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: LAURIE LADUCA
Title or Position: MANAGER
Credential:
Phone: 845-702-2711