Healthcare Provider Details

I. General information

NPI: 1194045914
Provider Name (Legal Business Name): CARE STATION MEDICAL GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 PROSPECT AVE
WEST ORANGE NJ
07052-4112
US

IV. Provider business mailing address

PO BOX 352
LINDEN NJ
07036-0352
US

V. Phone/Fax

Practice location:
  • Phone: 973-731-6767
  • Fax: 973-731-9881
Mailing address:
  • Phone: 908-925-7519
  • Fax: 908-925-2842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MIRANDA J AGOSTO
Title or Position: BILLING MANAGER
Credential:
Phone: 908-925-7519