Healthcare Provider Details

I. General information

NPI: 1114915469
Provider Name (Legal Business Name): MYLAN LAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 03/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 PLEASANT VALLEY WAY
WEST ORANGE NJ
07052-1424
US

IV. Provider business mailing address

4716 OLD GETTYSBURG RD LEGAL DEPARTMENT
MECHANICSBURG PA
17055-4325
US

V. Phone/Fax

Practice location:
  • Phone: 973-731-3600
  • Fax:
Mailing address:
  • Phone: 717-972-1139
  • Fax: 717-975-9981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number25MA06982800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number25MA06982800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: