Provider Demographics
NPI:1053632380
Name:INFECTIOUS DISEASES SERVICES OF NEW JERSEY LLC
Entity Type:Organization
Organization Name:INFECTIOUS DISEASES SERVICES OF NEW JERSEY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKHAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:MOURAVSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-953-6673
Mailing Address - Street 1:511 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2636
Mailing Address - Country:US
Mailing Address - Phone:973-200-3600
Mailing Address - Fax:973-821-3651
Practice Address - Street 1:511 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-2636
Practice Address - Country:US
Practice Address - Phone:973-200-3600
Practice Address - Fax:973-821-3651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty