Provider Demographics
NPI:1417170937
Name:GEORGE PAVLOU, MD, LLC
Entity Type:Organization
Organization Name:GEORGE PAVLOU, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:PUCHIK
Authorized Official - Suffix:
Authorized Official - Credentials:OFFICE MANAGER
Authorized Official - Phone:973-256-5557
Mailing Address - Street 1:19 YAWPO AVE.
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07436
Mailing Address - Country:US
Mailing Address - Phone:201-337-3412
Mailing Address - Fax:201-337-3353
Practice Address - Street 1:19 YAWPO AVE.
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:NJ
Practice Address - Zip Code:07436
Practice Address - Country:US
Practice Address - Phone:201-337-3412
Practice Address - Fax:201-337-3353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1039300Medicaid
NJ5395305Medicaid
NJPA674366Medicare ID - Type Unspecified
NJ1039300Medicaid