Provider Demographics
NPI:1255428322
Name:PHARISS, BRUCE (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:PHARISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 HILLSIDE AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2129
Mailing Address - Country:US
Mailing Address - Phone:973-509-2371
Mailing Address - Fax:973-744-9003
Practice Address - Street 1:8 HILLSIDE AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2129
Practice Address - Country:US
Practice Address - Phone:973-509-2371
Practice Address - Fax:973-744-9003
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-09
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1887842084P0802X, 2084P0800X
NJ25MA081859002084P0800X, 2084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF97359Medicare UPIN