Provider Demographics
NPI:1235317967
Name:GARDEN STATE FAMILY CARE ASSOCIATES LLC
Entity Type:Organization
Organization Name:GARDEN STATE FAMILY CARE ASSOCIATES LLC
Other - Org Name:GARDEN STATE FAMILY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:TATIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOURAVSKAIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-821-3640
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:973-821-3640
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:973-821-3640
Practice Address - Fax:973-821-3651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty