Healthcare Provider Details

I. General information

NPI: 1902804693
Provider Name (Legal Business Name): ATLANTIC GYNECOLOGIC ON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3349 HWY 138 BLDG B SUITE F
WALL TOWNSHIP NJ
07719-9671
US

IV. Provider business mailing address

3349 HWY 138 BLDG B SUITE F
WALL TOWNSHIP NJ
07719-9671
US

V. Phone/Fax

Practice location:
  • Phone: 732-280-5464
  • Fax: 732-280-5443
Mailing address:
  • Phone: 732-280-5464
  • Fax: 732-280-5443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberMB48253
License Number StateNJ

VIII. Authorized Official

Name: MRS. LISA ANN MENDUM
Title or Position: PRACTICE MANAGER
Credential:
Phone: 732-280-5464