Provider Demographics
NPI:1306471065
Name:AUTUMN RIDGE PRIMARY CARE LLC
Entity type:Organization
Organization Name:AUTUMN RIDGE PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:SICILIANO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:732-974-1980
Mailing Address - Street 1:3350 HWY 138 STE 217
Mailing Address - Street 2:
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-9694
Mailing Address - Country:US
Mailing Address - Phone:732-974-1980
Mailing Address - Fax:732-974-8020
Practice Address - Street 1:3350 HWY 138 STE 217
Practice Address - Street 2:
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-9694
Practice Address - Country:US
Practice Address - Phone:732-974-1980
Practice Address - Fax:732-974-8020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-03
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty