Provider Demographics
NPI:1447392162
Name:ENGLEWOOD MEDICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:ENGLEWOOD MEDICAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHYSICIAN NETWORK REVEN
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:LASNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-608-2136
Mailing Address - Street 1:375 ENGLE ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-1823
Mailing Address - Country:US
Mailing Address - Phone:201-608-2136
Mailing Address - Fax:201-894-5209
Practice Address - Street 1:350 ENGLE ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-1808
Practice Address - Country:US
Practice Address - Phone:201-894-3689
Practice Address - Fax:201-541-2965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NJ25MA07266800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ043858Medicare ID - Type Unspecified
NJ070144Medicare ID - Type Unspecified
NJC52739Medicare UPIN
NJG81847Medicare UPIN