=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063145894
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PODIATRY & ANKLE CENTER OF EXCELLENCE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2022
-----------------------------------------------------
Last Update Date | 10/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 59 VERONICA AVE STE 204
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08873-3579
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-978-2700
-----------------------------------------------------
Fax | 833-471-4443
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27 CELLER RD
-----------------------------------------------------
City | EDISON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08817-2971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-674-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PODIATRIST
-----------------------------------------------------
Name | DR. MARNI BRODER
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 732-978-2700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------