MEDICARE: 96TH STREET URGENT CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	MB72117	NJ

General Provider Information

NPI Number	:	1235359001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	96TH STREET URGENT CARE

Provider Business Mailing Address
First Line	:	376 96TH ST
Second Line	:	SUITE # 2
City	:	STONE HARBOR
State	:	NJ
Zip	:	08247-1404
Country	:	US
Telephone Number	:	609-368-3500
Fax Number	:	609-967-0077

Provider Business Practice Location Address
First Line	:	376 96TH ST
Second Line	:	SUITE # 2
City	:	STONE HARBOR
State	:	NJ
Zip	:	08247-1404
Country	:	US
Telephone Number	:	609-368-3500
Fax Number	:	609-967-0077

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TARA A VOGDES
Credential	:	DO
Telephone Number	:	609-967-0070

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	08/22/2020

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