Provider Demographics
NPI:1164732095
Name:FAMILY DERMATOLOGY OF NEW JERSEY PC
Entity Type:Organization
Organization Name:FAMILY DERMATOLOGY OF NEW JERSEY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:M
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-637-9982
Mailing Address - Street 1:40 MORRIS AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3300
Mailing Address - Country:US
Mailing Address - Phone:215-519-5487
Mailing Address - Fax:
Practice Address - Street 1:901 W MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2537
Practice Address - Country:US
Practice Address - Phone:732-637-9982
Practice Address - Fax:215-383-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-13
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207N00000X, 207ND0101X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ196380Medicare PIN