Healthcare Provider Details

I. General information

NPI: 1891767901
Provider Name (Legal Business Name): MICHAEL ANTHONY PRYBICIEN A.T.C. EMTB, C.S.C.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 06/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

799 BLOOMFIELD AVENUE SUITE 304
VERONA NJ
07044-1301
US

IV. Provider business mailing address

102 PATRICIA PL
CLIFTON NJ
07012-1855
US

V. Phone/Fax

Practice location:
  • Phone: 973-571-0001
  • Fax: 973-571-4170
Mailing address:
  • Phone: 973-594-9651
  • Fax: 973-571-4170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00062100
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT001246A
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: