=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346482726
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANTAGE PHYSICAL THERAPY OF NEW JERSEY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2009
-----------------------------------------------------
Last Update Date | 03/31/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 95 MADISON AVE SUITE A07
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07960-6092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-455-7121
-----------------------------------------------------
Fax | 973-455-1895
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 95 MADISON AVE SUITE A07
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07960-6092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-455-7121
-----------------------------------------------------
Fax | 973-455-1895
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. SUSAN M. KOHN
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 973-455-7121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 40QA00256000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------