=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245523869
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRACTICE ASSOCIATES MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2011
-----------------------------------------------------
Last Update Date | 01/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 385 MORRIS AVE SUITE 100
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07081-1151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-379-2111
-----------------------------------------------------
Fax | 973-379-2807
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 416457
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02241-6457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-362-1735
-----------------------------------------------------
Fax | 973-290-8349
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | CHRISTOPHER ALOYCE HERZOG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-829-4320
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------