Healthcare Provider Details

I. General information

NPI: 1922163104
Provider Name (Legal Business Name): SOUTH RIVER MEDICAL ASSOCIATES,P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 03/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 MAIN ST
SOUTH RIVER NJ
08882-1231
US

IV. Provider business mailing address

123 MAIN ST
SOUTH RIVER NJ
08882-1231
US

V. Phone/Fax

Practice location:
  • Phone: 732-254-3892
  • Fax: 732-254-9037
Mailing address:
  • Phone: 732-254-3892
  • Fax: 732-254-9037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMB24981
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMA63986
License Number StateNJ

VIII. Authorized Official

Name: DR. SIGMUND LEWIS KULESSA JR.
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 732-254-3892