MEDICARE: OPHTHALMOLOGY OF MONTCLAIR LIMITED LIABILITY COMPANY

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	207W00000X	Ophthalmology Physician	25MA07491800	NJ

General Provider Information

NPI Number	:	1912047713
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPHTHALMOLOGY OF MONTCLAIR LIMITED LIABILITY COMPANY

Provider Business Mailing Address
First Line	:	33 N FULLERTON AVE
Second Line	:	1ST FLOOR
City	:	MONTCLAIR
State	:	NJ
Zip	:	07042-3412
Country	:	US
Telephone Number	:	973-509-6039
Fax Number	:	973-509-6069

Provider Business Practice Location Address
First Line	:	33 N FULLERTON AVE
Second Line	:	1ST FLOOR
City	:	MONTCLAIR
State	:	NJ
Zip	:	07042-3412
Country	:	US
Telephone Number	:	973-509-6039
Fax Number	:	973-509-6069

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KATHRYN PHYLLIS CHILDS
Credential	:	MD
Telephone Number	:	973-509-6039

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	08/27/2007

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