=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285661579
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH JERSEY CENTER FOR UROLOGIC CARE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 POCONO RD SUITE 114
-----------------------------------------------------
City | DENVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07834-2901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-586-3056
-----------------------------------------------------
Fax | 973-625-0116
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 POCONO RD SUITE 114
-----------------------------------------------------
City | DENVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07834-2901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-586-3056
-----------------------------------------------------
Fax | 973-625-0116
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MS. COLLEEN CHRISTY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-586-3056
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 25MA02409000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------