=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033444021
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIGH CREST MEDICAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2009
-----------------------------------------------------
Last Update Date | 10/08/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 FAIRFIELD RD
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07004-2414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-808-5550
-----------------------------------------------------
Fax | 973-808-5999
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 FAIRFIELD RD
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07004-2414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-808-5550
-----------------------------------------------------
Fax | 973-808-5999
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. EUGENE L EVANS II
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 973-808-5550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------