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General NPI Number Information
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NPI Number | 1487840203
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Entity Type | Organization
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Legal Business Name | PROVIDENTIAL MEDICAL CENTER PC
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Dates
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Enumeration Date | 09/16/2007
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Last Update Date | 02/14/2011
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Provider Practice Location Address
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Address Line | 66 BRIDGE AVE # C
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City | RED BANK
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State | NJ
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Zip | 07701-6410
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Country | US
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Telephone | 732-747-6600
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Fax |
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Provider Business Mailing Address
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Address Line | 66 BRIDGE AVE # C
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City | RED BANK
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State | NJ
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Zip | 07701-6410
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Country | US
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Telephone |
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Fax | 732-747-6001
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Authorized Official
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Title or Position | OWNER
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Name | DAVID HYPPOLITE
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Credential | MD
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Telephone | 732-747-6600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MA61338
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License Number State | NJ
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