Provider Demographics
NPI:1164690061
Name:PHYSICAL MEDICINE AND ELECTRODIAGNOSIS LLC
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE AND ELECTRODIAGNOSIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:KALYOUSSEF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-998-6487
Mailing Address - Street 1:2932 ROUTE 10 WEST
Mailing Address - Street 2:
Mailing Address - City:MORRIS PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07950
Mailing Address - Country:US
Mailing Address - Phone:973-998-6487
Mailing Address - Fax:973-998-6491
Practice Address - Street 1:2932 ROUTE 10 WEST
Practice Address - Street 2:
Practice Address - City:MORRIS PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07950
Practice Address - Country:US
Practice Address - Phone:973-998-6487
Practice Address - Fax:973-998-6491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ501172081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD93291Medicare UPIN
NJ146353Medicare PIN