=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992057095
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANNA SHOSHILOS, D.O, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2012
-----------------------------------------------------
Last Update Date | 10/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 784 CHIMNEY ROCK RD SUITE: G
-----------------------------------------------------
City | MARTINSVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08836-2272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-271-1771
-----------------------------------------------------
Fax | 732-271-9477
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 96 LINWOOD PLZ SUITE NUMBER: 347
-----------------------------------------------------
City | FORT LEE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07024-3701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-699-9765
-----------------------------------------------------
Fax | 347-474-7300
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ANNA SHOSHILOS
-----------------------------------------------------
Credential | D.O
-----------------------------------------------------
Telephone | 973-699-6765
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 25MB06906000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------