Provider Demographics
NPI:1194033613
Name:FAMILY MEDICAL GROUP SERVICES LLC
Entity Type:Organization
Organization Name:FAMILY MEDICAL GROUP SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:862-520-3902
Mailing Address - Street 1:134 EVERGREEN PL STE 501
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-2010
Mailing Address - Country:US
Mailing Address - Phone:862-520-3902
Mailing Address - Fax:862-520-3895
Practice Address - Street 1:134 EVERGREEN PL STE 501
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2010
Practice Address - Country:US
Practice Address - Phone:862-520-3902
Practice Address - Fax:862-520-3895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-17
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty