Provider Demographics
NPI:1407137292
Name:WELLCOMECARE PHYSICIAN GROUP PC
Entity Type:Organization
Organization Name:WELLCOMECARE PHYSICIAN GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/ MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANASTASI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-773-3800
Mailing Address - Street 1:1373 BROAD ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-4200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 PASSAIC ST
Practice Address - Street 2:
Practice Address - City:GARFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07026
Practice Address - Country:US
Practice Address - Phone:973-773-3800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08742300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
217130YEMNOtherMEDICARE PTAN