Provider Demographics
NPI:1497149082
Name:NORTHEAST NEUROSURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:NORTHEAST NEUROSURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:POULAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-688-8800
Mailing Address - Street 1:1057 COMMERCE AVE
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-5025
Mailing Address - Country:US
Mailing Address - Phone:908-688-8800
Mailing Address - Fax:908-688-2377
Practice Address - Street 1:1057 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-5025
Practice Address - Country:US
Practice Address - Phone:908-688-8800
Practice Address - Fax:908-688-2377
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IGEA BRAIN & SPINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08517100207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0198838Medicaid
NJ177179RRQMedicare PIN