Provider Demographics
NPI:1053343657
Name:MEDFORD, SUSAN (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MEDFORD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 ROUTE 35
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-5037
Mailing Address - Country:US
Mailing Address - Phone:973-467-7976
Mailing Address - Fax:973-467-7971
Practice Address - Street 1:226 MIDDLE RD
Practice Address - Street 2:SUITE 5
Practice Address - City:HAZLET
Practice Address - State:NJ
Practice Address - Zip Code:07730-1945
Practice Address - Country:US
Practice Address - Phone:732-888-9889
Practice Address - Fax:732-888-9897
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00661800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ086999TPGMedicare ID - Type Unspecified