=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790820496
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLOWBROOK OBSTETRICS AND GYNECOLOGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 57 WILLOWBROOK BLVD SUITE 301
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07470-7045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-754-4075
-----------------------------------------------------
Fax | 973-256-6523
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 57 WILLOWBROOK BLVD. SUITE 301
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-754-4075
-----------------------------------------------------
Fax | 973-256-6523
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. ROGER P KIERCE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 973-754-4975
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 25MA05001400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------