Healthcare Provider Details

I. General information

NPI: 1811382096
Provider Name (Legal Business Name): UNIVERSITY MEDICAL AND TREATMENT CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2015
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 CLYDE RD SUITE 105
SOMERSET NJ
08873-5032
US

IV. Provider business mailing address

33 CLYDE RD SUITE 105
SOMERSET NJ
08873-5032
US

V. Phone/Fax

Practice location:
  • Phone: 732-247-9001
  • Fax: 732-247-9002
Mailing address:
  • Phone: 732-247-9001
  • Fax: 732-247-9002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA06645800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. NOEL ILOGU
Title or Position: PRESIDENT
Credential: M.D.
Phone: 732-247-9001