=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760535769
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEROME KESSELMAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2007
-----------------------------------------------------
Last Update Date | 03/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41 FREDONIA RD
-----------------------------------------------------
City | FREDON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07860-5203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-383-7689
-----------------------------------------------------
Fax | 973-383-2401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 FREDONIA RD
-----------------------------------------------------
City | FREDON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07860-5203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-383-7689
-----------------------------------------------------
Fax | 973-383-2401
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | MA24905
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------