=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881898575
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN POLITO NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 CRAIG RD STE 205A
-----------------------------------------------------
City | MANALAPAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07726-8731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-866-9922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31 CRUSIUS PL
-----------------------------------------------------
City | COLTS NECK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07722-1630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-462-8924
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 26NJ300077400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------