=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750337564
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH JERSEY REHAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2006
-----------------------------------------------------
Last Update Date | 03/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 504 HAMBURG TPKE STE B105
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07470-2034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-595-0063
-----------------------------------------------------
Fax | 973-240-8990
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 43092
-----------------------------------------------------
City | UPPER MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07043-0092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-595-0063
-----------------------------------------------------
Fax | 973-720-0408
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CYRUS R VOSOUGH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 973-595-0063
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MA70629
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------