Healthcare Provider Details

I. General information

NPI: 1912163486
Provider Name (Legal Business Name): MILLTOWN MEDICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 05/21/2013
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 Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number25MB06359800
License Number StateNJ

VIII. Authorized Official

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