Organization
OB GYN PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CYNTHIA E CHETTUM (OFFICE MANAGER)
(201) 487-3464
Entity
Organization
Contact information
Practice address
20 PROSPECT AVENUE, SUITE 607, HACKENSACK, NJ 07601
(201) 487-3464
(201) 487-0232
Mailing address
20 PROSPECT AVENUE, SUITE 607, HACKENSACK, NJ 07601
(201) 487-3464
(201) 487-0232
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0511943
AETNA HMO GROUP #
NJ
01
—
8750176
AETNA PPO GROUP #
NJ
01
—
CF1821
RR MDCR GROUP #
NJ
Enumeration date
11/15/2006
Last updated
04/17/2008
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