1063739829 NPI number — INTEGRATIVE FUNCTIONAL MEDICINE ASSOCIATES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063739829 NPI number — INTEGRATIVE FUNCTIONAL MEDICINE ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATIVE FUNCTIONAL MEDICINE ASSOCIATES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063739829
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
41 WATCHUNG PLZ
Provider Second Line Business Mailing Address:
SUITE 345
Provider Business Mailing Address City Name:
MONTCLAIR
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07042-4117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-967-8425
Provider Business Mailing Address Fax Number:
201-967-8443

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
292 BLOOMFIELD AVE
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
MONTCLAIR
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07042-3624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-928-8909
Provider Business Practice Location Address Fax Number:
201-967-8425
Provider Enumeration Date:
05/03/2010

Additional Information

Authorized Official

Authorized Official Last Name:
THOMAS
Authorized Official First Name:
JODI
Authorized Official Middle Name:
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
201-967-8425

Provider Taxonomy Codes

  • Taxonomy code: 2081P0004X , with the licence number:  25MA07295900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 005466 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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