Provider Demographics
NPI:1790820496
Name:WILLOWBROOK OBSTETRICS AND GYNECOLOGY LLC
Entity Type:Organization
Organization Name:WILLOWBROOK OBSTETRICS AND GYNECOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:P
Authorized Official - Last Name:KIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-754-4975
Mailing Address - Street 1:57 WILLOWBROOK BLVD.
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470
Mailing Address - Country:US
Mailing Address - Phone:973-754-4075
Mailing Address - Fax:973-256-6523
Practice Address - Street 1:57 WILLOWBROOK BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-7045
Practice Address - Country:US
Practice Address - Phone:973-754-4075
Practice Address - Fax:973-256-6523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05001400207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH5231507Medicaid
NH5231507Medicaid
NJF37742Medicare UPIN