=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053316695
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JERSEY SHORE MONMOUTH COUNTY ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1930 CORLIES AVE
-----------------------------------------------------
City | NEPTUNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07753-4842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-775-8789
-----------------------------------------------------
Fax | 732-502-4435
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 23958
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07189-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-263-7935
-----------------------------------------------------
Fax | 732-263-7921
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MS. ANN DALTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 732-775-8789
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | MA19998
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------