Healthcare Provider Details

I. General information

NPI: 1821742487
Provider Name (Legal Business Name): STATEN ISLAND REPRODUCTIVE MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2022
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 SOUTH AVE # 201
STATEN ISLAND NY
10314-3425
US

IV. Provider business mailing address

94 OLD SHORT HILLS RD STE 403
LIVINGSTON NJ
07039-5672
US

V. Phone/Fax

Practice location:
  • Phone: 973-548-0900
  • Fax:
Mailing address:
  • Phone: 973-548-0900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA MILLER
Title or Position: FINANCE MANAGER
Credential:
Phone: 732-317-8286