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General NPI Number Information
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NPI Number | 1811229875
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Entity Type | Organization
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Legal Business Name | LONGEVITY MEDICAL GROUP, P.A.
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Dates
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Enumeration Date | 02/02/2010
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Last Update Date | 02/02/2010
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Provider Practice Location Address
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Address Line | 2 SEARS DR
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City | PARAMUS
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State | NJ
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Zip | 07652-3539
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Country | US
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Telephone | 201-265-4647
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 8069
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City | PARAMUS
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State | NJ
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Zip | 07653-8069
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Country | US
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Telephone | 201-265-4647
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ROGER HOWARD COLETTI
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Credential | MD
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Telephone | 201-265-4647
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MA42243
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License Number State | NJ
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