Provider Demographics
NPI:1447470125
Name:EAR NOSE & THROAT OF FREEHOLD LLC
Entity type:Organization
Organization Name:EAR NOSE & THROAT OF FREEHOLD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:ROESSLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:732-677-3780
Mailing Address - Street 1:55-77 SCHANCK RD
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2964
Mailing Address - Country:US
Mailing Address - Phone:732-677-3780
Mailing Address - Fax:732-677-3782
Practice Address - Street 1:55-77 SCHANCK RD
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2964
Practice Address - Country:US
Practice Address - Phone:732-677-3780
Practice Address - Fax:732-677-3782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07718700207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJI15728Medicare UPIN