Provider Demographics
NPI:1457482614
Name:MEDICAL & SURGICAL FAMILY PRACTICE OF PASSAIC P A
Entity Type:Organization
Organization Name:MEDICAL & SURGICAL FAMILY PRACTICE OF PASSAIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:TELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-777-3006
Mailing Address - Street 1:PO BOX 2007
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07509-2007
Mailing Address - Country:US
Mailing Address - Phone:973-777-3006
Mailing Address - Fax:973-777-5587
Practice Address - Street 1:121 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-4926
Practice Address - Country:US
Practice Address - Phone:973-777-3006
Practice Address - Fax:973-777-5587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04703100208600000X, 2086S0129X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6688608Medicaid
NJ6688608Medicaid