1346417409 NPI number — DR. MIRIC NEUROLOGY CENTER

Table of content: (NPI 1346417409)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346417409 NPI number — DR. MIRIC NEUROLOGY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. MIRIC NEUROLOGY CENTER
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:
1346417409
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 W MAIN ST
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
DENVILLE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07834-2174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-625-0588
Provider Business Mailing Address Fax Number:
973-625-0589

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 W MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
DENVILLE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07834-2174
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-625-0588
Provider Business Practice Location Address Fax Number:
973-625-0589
Provider Enumeration Date:
05/08/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MIRIC
Authorized Official First Name:
SLOBODAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
973-625-0588

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  25MA08380900 , 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)