=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437371762
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORTHOPAEDIC SURGERY SPECIALIST OF MONTCLAIR, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 08/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 PARK ST SUITE #1G
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-5913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-744-7900
-----------------------------------------------------
Fax | 973-744-7995
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 PARK ST SUITE #1G
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-5913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-744-7900
-----------------------------------------------------
Fax | 973-744-7995
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. EVAN SCOTT FISCHER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 973-744-7900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0106X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Hand Surgery Physician
-----------------------------------------------------
License Number | MA067272
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------