Healthcare Provider Details

I. General information

NPI: 1417915968
Provider Name (Legal Business Name): THADDEUS M AVERSA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 COVENTRY CENTRE DR
PHILLIPSBURG NJ
08865
US

IV. Provider business mailing address

PO BOX 27957
SALT LAKE CITY UT
84127-0957
US

V. Phone/Fax

Practice location:
  • Phone: 908-454-9902
  • Fax: 908-454-9905
Mailing address:
  • Phone: 908-835-1910
  • Fax: 908-835-1924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB065920
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS008958L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS008958L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: