Healthcare Provider Details

I. General information

NPI: 1487192324
Provider Name (Legal Business Name): CMMC PROVIDER SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2017
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 OLD SHORT HILLS RD
WEST ORANGE NJ
07052-1008
US

IV. Provider business mailing address

95 OLD SHORT HILLS RD
WEST ORANGE NJ
07052-1008
US

V. Phone/Fax

Practice location:
  • Phone: 732-423-7497
  • Fax:
Mailing address:
  • Phone: 732-423-7497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE MINTZ
Title or Position: DIR. FINANCE
Credential:
Phone: 732-423-7497