=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265432595
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE NEUROSCIENCE CENTER OF NORTHERN NEW JERSEY , PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2005
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 MADISON AVE
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07960-6909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-285-1446
-----------------------------------------------------
Fax | 973-605-8854
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 MADISON AVE SUITE 120
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07960-6909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-285-1446
-----------------------------------------------------
Fax | 973-605-8854
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARK DIAMOND
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 973-285-1446
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------