Provider Demographics
NPI:1659523371
Name:MCM PT SERVICE
Entity Type:Organization
Organization Name:MCM PT SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPEARS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-741-0678
Mailing Address - Street 1:130 MAPLE AVE
Mailing Address - Street 2:SUITE 4A
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-1734
Mailing Address - Country:US
Mailing Address - Phone:732-741-0678
Mailing Address - Fax:
Practice Address - Street 1:130 MAPLE AVE
Practice Address - Street 2:SUITE 4A
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1734
Practice Address - Country:US
Practice Address - Phone:732-741-0678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-13
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00369200225100000X
NJ40QA00544800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ042565Medicare UPIN
NJ077935Medicare UPIN