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General NPI Number Information
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NPI Number | 1568409464
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Entity Type | Organization
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Legal Business Name | NEPHROLOGY SERVICES MEDICAL GROUP OF NEW JERSEY
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Dates
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Enumeration Date | 05/31/2006
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Last Update Date | 03/23/2011
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Provider Practice Location Address
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Address Line | 721 N BEERS ST SUITE 1F
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City | HOLMDEL
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State | NJ
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Zip | 07733-1518
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Country | US
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Telephone | 732-888-9100
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Fax | 732-888-5515
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Provider Business Mailing Address
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Address Line | 721 N BEERS ST SUITE 1F
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City | HOLMDEL
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State | NJ
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Zip | 07733-1518
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Country | US
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Telephone | 732-888-9100
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Fax | 732-888-5515
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JEAN A. OTRAKJI
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Credential | M.D.
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Telephone | 732-888-9100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | 25MA04735600
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License Number State | NJ
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