Healthcare Provider Details

I. General information

NPI: 1386003580
Provider Name (Legal Business Name): EPILEPSY & NEUROPHYSIOLOGY MEDICAL CONSULTANTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CAPITAL WAY 3RD FLOOR, SUITE 385
PENNINGTON NJ
08534-2521
US

IV. Provider business mailing address

690 N BROADWAY GL1
N WHITE PLAINS NY
10603-2417
US

V. Phone/Fax

Practice location:
  • Phone: 908-522-4990
  • Fax: 973-538-0043
Mailing address:
  • Phone: 914-428-3651
  • Fax: 914-428-2648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHELLEY INFELD
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 914-428-3651