Provider Demographics
NPI:1477874352
Name:ITSERGA MEDICAL LLC
Entity Type:Organization
Organization Name:ITSERGA MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:V
Authorized Official - Last Name:AGRESTI
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:973-284-0777
Mailing Address - Street 1:181 FRANKLIN AVE
Mailing Address - Street 2:SUITE#201
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-3820
Mailing Address - Country:US
Mailing Address - Phone:973-284-0777
Mailing Address - Fax:973-284-1530
Practice Address - Street 1:181 FRANKLIN AVE
Practice Address - Street 2:SUITE#201
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-3820
Practice Address - Country:US
Practice Address - Phone:973-284-0777
Practice Address - Fax:973-284-1530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07826100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ085650Medicare PIN