Healthcare Provider Details

I. General information

NPI: 1700124922
Provider Name (Legal Business Name): MILLTOWN MEDICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2013
Last Update Date: 01/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 MILLTOWN RD
SPRINGFIELD NJ
07081-2445
US

IV. Provider business mailing address

406 MILLTOWN RD
SPRINGFIELD NJ
07081-2445
US

V. Phone/Fax

Practice location:
  • Phone: 973-921-1777
  • Fax: 973-921-1790
Mailing address:
  • Phone: 973-921-1777
  • Fax: 973-921-1790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number25MA5507600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA04456500
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP00211500
License Number StateNJ

VIII. Authorized Official

Name: MRS. ANNA TOME
Title or Position: BILLING
Credential:
Phone: 973-921-1777