Provider Demographics
NPI:1346346103
Name:OM MEDICAL CENTER LLC.
Entity Type:Organization
Organization Name:OM MEDICAL CENTER LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUSHYANT
Authorized Official - Middle Name:R
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-773-6868
Mailing Address - Street 1:12-15 BROADWAY STE B
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-2031
Mailing Address - Country:US
Mailing Address - Phone:201-773-6868
Mailing Address - Fax:201-773-6867
Practice Address - Street 1:12-15 BROADWAY STE B
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-2031
Practice Address - Country:US
Practice Address - Phone:201-773-6868
Practice Address - Fax:201-773-6867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0108871Medicaid
NJ0108871Medicaid
I01408Medicare UPIN