Provider Demographics
NPI:1306290655
Name:ADVANCED METABOLIC MEDICINE
Entity type:Organization
Organization Name:ADVANCED METABOLIC MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-857-5882
Mailing Address - Street 1:42 S MAPLE AVE
Mailing Address - Street 2:STE A
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4508
Mailing Address - Country:US
Mailing Address - Phone:201-857-5882
Mailing Address - Fax:973-215-2052
Practice Address - Street 1:42 S MAPLE AVE
Practice Address - Street 2:STE A
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4508
Practice Address - Country:US
Practice Address - Phone:201-857-5882
Practice Address - Fax:973-215-2052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-22
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09133000261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care