Provider Demographics
NPI:1528199890
Name:MOUNTAINSIDE FAMILY PRACTICE ASSOCIATES - MERIT
Entity Type:Organization
Organization Name:MOUNTAINSIDE FAMILY PRACTICE ASSOCIATES - MERIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C E O
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DYKES
Authorized Official - Suffix:
Authorized Official - Credentials:MR
Authorized Official - Phone:973-429-6000
Mailing Address - Street 1:799 BLOOMFIELD AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-1367
Mailing Address - Country:US
Mailing Address - Phone:973-746-7050
Mailing Address - Fax:973-857-2831
Practice Address - Street 1:799 BLOOMFIELD AVENUE
Practice Address - Street 2:SUITE 201
Practice Address - City:VERONA
Practice Address - State:NJ
Practice Address - Zip Code:07044-0000
Practice Address - Country:US
Practice Address - Phone:973-746-7050
Practice Address - Fax:973-857-2831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4138708Medicaid
NJ310054Medicare ID - Type Unspecified