Basic Information
| Provider Information | |||||||||
| NPI: | 1083695258 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUTKIN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 254B MOUNTAIN AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | HACKETTSTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078402413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9086845800 | ||||||||
| FaxNumber: | 9086845606 | ||||||||
| Practice Location | |||||||||
| Address1: | 254B MOUNTAIN AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | HACKETTSTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078402413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9086845800 | ||||||||
| FaxNumber: | 9086845606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 10/27/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 25MA07353600 | NJ | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 9042806 | 05 | NJ | MEDICAID |