MEDICARE: JEFFREY PAUL TAKACH PA-C

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	363A00000X	Physician Assistant	25MP00026700	NJ

General Provider Information

NPI Number	:	1285684670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY PAUL TAKACH PA-C

Provider Business Mailing Address
First Line	:	411 S RIVERSIDE DR
Second Line	:
City	:	NEPTUNE
State	:	NJ
Zip	:	07753-5840
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 CENTER PLZ
Second Line	:
City	:	TINTON FALLS
State	:	NJ
Zip	:	07724-9744
Country	:	US
Telephone Number	:	732-460-5360
Fax Number	:	732-460-7442

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	07/08/2007

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