Provider Demographics
NPI:1538318795
Name:INTERNAL MEDICINE & GERIATRIC SPECIALIST OF NORTH JERSEY, LLC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE & GERIATRIC SPECIALIST OF NORTH JERSEY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT EXECUTIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBI
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-376-0770
Mailing Address - Street 1:2811 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-2227
Mailing Address - Country:US
Mailing Address - Phone:201-319-0008
Mailing Address - Fax:201-319-0004
Practice Address - Street 1:2811 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-2227
Practice Address - Country:US
Practice Address - Phone:201-319-0008
Practice Address - Fax:201-319-0004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07249800207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ469233Medicare UPIN