Provider Demographics
NPI:1508413097
Name:PROGRESSIVE MEDICAL PLLC
Entity Type:Organization
Organization Name:PROGRESSIVE MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ENABOSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-280-9600
Mailing Address - Street 1:460 N MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07017-4674
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:455 JERSEY ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2976
Practice Address - Country:US
Practice Address - Phone:718-524-5611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-20
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04996732Medicaid