Healthcare Provider Details

I. General information

NPI: 1396954145
Provider Name (Legal Business Name): GRETCHEN B. FAHRENBRUCH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 MONTGOMERY ST
PRINCETON JCT NJ
08550-1335
US

IV. Provider business mailing address

54 MONTGOMERY ST
PRINCETON JCT NJ
08550-1335
US

V. Phone/Fax

Practice location:
  • Phone: 609-799-1814
  • Fax: 609-799-2574
Mailing address:
  • Phone: 609-799-1814
  • Fax: 609-799-2574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MA05282300
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberMA52823
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: