Healthcare Provider Details

I. General information

NPI: 1235978784
Provider Name (Legal Business Name): STEPHEN DONALD HUSCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SPRINGFIELD AVE FL 3
SUMMIT NJ
07901-4055
US

IV. Provider business mailing address

PO BOX 416457
BOSTON MA
02241-1326
US

V. Phone/Fax

Practice location:
  • Phone: 908-934-0555
  • Fax: 908-934-0556
Mailing address:
  • Phone: 842-362-1735
  • Fax: 973-290-7495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00842400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: