Provider Demographics
NPI:1528231875
Name:MONTVILLE PARK PHYSICIAN ASSOCIATES
Entity Type:Organization
Organization Name:MONTVILLE PARK PHYSICIAN ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAGIH
Authorized Official - Middle Name:
Authorized Official - Last Name:WASSEF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-263-9900
Mailing Address - Street 1:150 RIVER RD
Mailing Address - Street 2:SUITE N1
Mailing Address - City:MONTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07045-9441
Mailing Address - Country:US
Mailing Address - Phone:973-263-9900
Mailing Address - Fax:
Practice Address - Street 1:150 RIVER RD
Practice Address - Street 2:SUITE N1
Practice Address - City:MONTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07045-9441
Practice Address - Country:US
Practice Address - Phone:973-263-9900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA061582207R00000X
NJMA081421208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6806104Medicaid
NJ6806104Medicaid