Provider Demographics
NPI:1295857365
Name:AHKAMI MEDICAL GROUP
Entity Type:Organization
Organization Name:AHKAMI MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAHROKH
Authorized Official - Middle Name:
Authorized Official - Last Name:STANCHAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:974-471-9585
Mailing Address - Street 1:110 PASSAIC AVE
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-4827
Mailing Address - Country:US
Mailing Address - Phone:973-471-9585
Mailing Address - Fax:973-471-8534
Practice Address - Street 1:110 PASSAIC AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-4827
Practice Address - Country:US
Practice Address - Phone:973-471-9585
Practice Address - Fax:973-471-8534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherTAX IDENTIFICATION NUMBER