=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760488373
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STUART MICHAEL HOMER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2005
-----------------------------------------------------
Last Update Date | 02/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1030 SAINT GEORGES AVE STE 201
-----------------------------------------------------
City | AVENEL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07001-1330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-602-0244
-----------------------------------------------------
Fax | 732-602-2577
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1030 SAINT GEORGES AVE STE 201
-----------------------------------------------------
City | AVENEL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07001-1330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-602-0244
-----------------------------------------------------
Fax | 732-602-2577
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | MA46118
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------