Basic Information
| Provider Information | |||||||||
| NPI: | 1437478898 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED WOUND SPECIALISTS OF ELIZABETH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 848591 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022848591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044463451 | ||||||||
| FaxNumber: | 9044463451 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 WILLIAMSON ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | ELIZABETH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 072023674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9089945480 | ||||||||
| FaxNumber: | 9089948802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2010 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | MORRISON | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 8556895105 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIVERSIFIED CLINICAL SERVICES | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 2083P0011X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200454 | 01 | NJ | GROUP MEDICARE PTAN | OTHER |