Provider Demographics
NPI:1346755402
Name:MIRMANESH MEDICINE
Entity Type:Organization
Organization Name:MIRMANESH MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRMANESH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-980-5672
Mailing Address - Street 1:100 ROUTE 73
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-9575
Mailing Address - Country:US
Mailing Address - Phone:856-753-7374
Mailing Address - Fax:
Practice Address - Street 1:100 ROUTE 73
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9575
Practice Address - Country:US
Practice Address - Phone:609-753-7374
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty