Healthcare Provider Details

I. General information

NPI: 1467701102
Provider Name (Legal Business Name): SHIJU SAM SCARIAH D.P.T
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2012
Last Update Date: 09/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 SEAVIEW DRIVE
SECAUCUS NJ
07094
US

IV. Provider business mailing address

186 OAK STREET
TEANECK NJ
07666
US

V. Phone/Fax

Practice location:
  • Phone: 201-319-1611
  • Fax:
Mailing address:
  • Phone: 201-837-7295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01460500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: