=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861446932
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREEHOLD OPHTHALMOLOGY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2006
-----------------------------------------------------
Last Update Date | 10/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 509 STILLWELLS CORNER RD STE E5
-----------------------------------------------------
City | FREEHOLD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07728-2965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-431-9333
-----------------------------------------------------
Fax | 732-431-3312
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 509 STILLWELLS CORNER RD SUITE E5
-----------------------------------------------------
City | FREEHOLD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07728-2965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-431-9333
-----------------------------------------------------
Fax | 732-431-3312
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ERIC ANDREW GERSHENBAUM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 732-431-9333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 25MA07781000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------