Provider Demographics
NPI:1982035093
Name:SUBURBAN FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:SUBURBAN FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-812-9091
Mailing Address - Street 1:40 MICHELLE WAY
Mailing Address - Street 2:
Mailing Address - City:PINE BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:07058-9446
Mailing Address - Country:US
Mailing Address - Phone:973-812-9091
Mailing Address - Fax:973-339-9040
Practice Address - Street 1:1031 MCBRIDE AVE
Practice Address - Street 2:SUITE D 210
Practice Address - City:WOODLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07424-2559
Practice Address - Country:US
Practice Address - Phone:973-812-9091
Practice Address - Fax:973-339-9040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-29
Last Update Date:2013-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06609700261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care