Provider Demographics
NPI:1881697373
Name:LEDEREICH, PHILIP STANLEY (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:STANLEY
Last Name:LEDEREICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 CLIFTON AVENUE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013
Mailing Address - Country:US
Mailing Address - Phone:973-470-8266
Mailing Address - Fax:973-470-8288
Practice Address - Street 1:1033 CLIFTON AVENUE
Practice Address - Street 2:SUITES 204 AND 206
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013
Practice Address - Country:US
Practice Address - Phone:973-470-8266
Practice Address - Fax:973-470-8288
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA062691207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F70841Medicare UPIN