Provider Demographics
NPI:1346407715
Name:IRONBOUND MEDICAL SERVICES, LLC
Entity Type:Organization
Organization Name:IRONBOUND MEDICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MUSTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-878-3990
Mailing Address - Street 1:221 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-1558
Mailing Address - Country:US
Mailing Address - Phone:973-878-3990
Mailing Address - Fax:
Practice Address - Street 1:221 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-1558
Practice Address - Country:US
Practice Address - Phone:973-878-3990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA053782261QP2300X, 261QU0200X, 261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE55343Medicare UPIN