Provider Demographics
NPI:1457611675
Name:SMC MED PA
Entity Type:Organization
Organization Name:SMC MED PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:T
Authorized Official - Last Name:DIERLAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-268-2754
Mailing Address - Street 1:PO POX 147
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:NJ
Mailing Address - Zip Code:07880
Mailing Address - Country:US
Mailing Address - Phone:201-804-2800
Mailing Address - Fax:
Practice Address - Street 1:61 MARBLE HILL RD
Practice Address - Street 2:
Practice Address - City:GREAT MEADOWS
Practice Address - State:NJ
Practice Address - Zip Code:07838-2314
Practice Address - Country:US
Practice Address - Phone:201-804-2800
Practice Address - Fax:201-804-8883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-22
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05562800207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty