1891880019 NPI number — TRISTATE MEDICAL ASSOCIATES, PC

Table of content: (NPI 1891880019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891880019 NPI number — TRISTATE MEDICAL ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRISTATE MEDICAL ASSOCIATES, PC
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:
1891880019
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 163
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSELAND
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07068-0163
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-614-9500
Provider Business Mailing Address Fax Number:
973-614-8200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
642 BROAD ST
Provider Second Line Business Practice Location Address:
2ND FLOOR, SUITE 9
Provider Business Practice Location Address City Name:
CLIFTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07013-1615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-614-9500
Provider Business Practice Location Address Fax Number:
973-614-8200
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BELOZERSKY
Authorized Official First Name:
MARINA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
973-614-9500

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MA072674 , 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)





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