Provider Demographics
NPI:1891016762
Name:RUTHERFORD WOMEN AND ADOLESCENT CARE, LLC
Entity Type:Organization
Organization Name:RUTHERFORD WOMEN AND ADOLESCENT CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:OSWALD
Authorized Official - Last Name:WITTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-438-0539
Mailing Address - Street 1:PO BOX 25
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-0025
Mailing Address - Country:US
Mailing Address - Phone:201-438-0539
Mailing Address - Fax:201-438-2108
Practice Address - Street 1:17 SYLVAN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070-2037
Practice Address - Country:US
Practice Address - Phone:201-438-0539
Practice Address - Fax:201-438-2108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMAO51466261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0777901Medicaid