1780113100 NPI number — FUSION REHABILITATIVE MEDICINE, LLC

Table of content: MIKAYLA ANNMARIE GREEN DPM (NPI 1477240125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780113100 NPI number — FUSION REHABILITATIVE MEDICINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FUSION REHABILITATIVE MEDICINE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780113100
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 HOSPITAL PLZ STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLD BRIDGE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08857-3084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-631-4410
Provider Business Mailing Address Fax Number:
844-350-5451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 HOSPITAL PLAZA
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
OLD BRIDGE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-631-4410
Provider Business Practice Location Address Fax Number:
844-350-5451
Provider Enumeration Date:
06/08/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MUNOZ
Authorized Official First Name:
MARA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
732-631-4410

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  25MA08584900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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