Healthcare Provider Details

I. General information

NPI: 1134668981
Provider Name (Legal Business Name): COMPLETE NEUROLOGICAL CARE OF NJ PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 02/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 GREGORY AVE SUITE 203
PASSAIC NJ
07055-4856
US

IV. Provider business mailing address

308 MYERS AVE
HASBROUCK HEIGHTS NJ
07604-2236
US

V. Phone/Fax

Practice location:
  • Phone: 212-349-2787
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number25MA09993200
License Number StateNJ

VIII. Authorized Official

Name: ELLEN I EDGAR
Title or Position: OWNER
Credential: M.D.
Phone: 212-349-2787