Healthcare Provider Details

I. General information

NPI: 1558738898
Provider Name (Legal Business Name): TIMOTHY MOMAH MT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2015
Last Update Date: 08/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 W LAKE AVE
RAHWAY NJ
07065-2537
US

IV. Provider business mailing address

536 W LAKE AVE
RAHWAY NJ
07065-2537
US

V. Phone/Fax

Practice location:
  • Phone: 848-467-9311
  • Fax:
Mailing address:
  • Phone: 848-467-9311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number015075-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: