Healthcare Provider Details

I. General information

NPI: 1316222664
Provider Name (Legal Business Name): RUTGERS HEALTH-RWJ SCLERODERMA PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 HOES LN W
PISCATAWAY NJ
08854-8021
US

IV. Provider business mailing address

66 W GILBERT ST 2ND FLOOR
TINTON FALLS NJ
07701-4947
US

V. Phone/Fax

Practice location:
  • Phone: 732-235-4402
  • Fax:
Mailing address:
  • Phone: 732-212-0051
  • Fax: 732-212-0713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: BRENDA LAWRENCE
Title or Position: DIRECTOR OF REVENUE CYCLE
Credential:
Phone: 732-235-6070