Healthcare Provider Details

I. General information

NPI: 1639895055
Provider Name (Legal Business Name): CHRYSALIS HEALTH OF NJ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

386 PARK AVE S FL 5
NEW YORK NY
10016-8815
US

IV. Provider business mailing address

136 E 76TH ST APT 8F
NEW YORK NY
10021-2831
US

V. Phone/Fax

Practice location:
  • Phone: 434-248-7508
  • Fax: 213-340-5870
Mailing address:
  • Phone: 434-248-7508
  • Fax: 213-340-5870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: ANDREW CUNNINGHAM
Title or Position: PRESIDENT
Credential: MD
Phone: 434-248-7508