Provider Demographics
NPI:1073904801
Name:AVICENNA MEDICAL CENTER
Entity Type:Organization
Organization Name:AVICENNA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:ROSSI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-746-2620
Mailing Address - Street 1:129 VALLEY RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2331
Mailing Address - Country:US
Mailing Address - Phone:973-746-2620
Mailing Address - Fax:973-746-2579
Practice Address - Street 1:129 VALLEY RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2331
Practice Address - Country:US
Practice Address - Phone:973-746-2620
Practice Address - Fax:973-746-2579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-16
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07627000103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Single Specialty