=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255658712
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RETINA CENTER OF NEW JERSEY PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2010
-----------------------------------------------------
Last Update Date | 05/25/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 509 E BROAD ST
-----------------------------------------------------
City | WESTFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07090-2115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-232-0909
-----------------------------------------------------
Fax | 908-232-4339
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 509 E BROAD ST
-----------------------------------------------------
City | WESTFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07090-2115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-232-0909
-----------------------------------------------------
Fax | 908-232-4339
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARVIN F KRAUSHAR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 908-232-0909
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 25MA02750700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------