=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265688774
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JERSEY SHORE FOOT AND LEG CENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2008
-----------------------------------------------------
Last Update Date | 08/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 SHAWNEE DR
-----------------------------------------------------
City | WATCHUNG
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07069-5803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-769-5337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 SHAWNEE DR
-----------------------------------------------------
City | WATCHUNG
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07069-5803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-769-5337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. KATHY MUHLHAUSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 908-769-5337
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | MD1954
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------