Provider Demographics
NPI:1578797759
Name:NATALYA AVANESOVA LLC
Entity Type:Organization
Organization Name:NATALYA AVANESOVA LLC
Other - Org Name:ANEW MEDICAL LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATALYA
Authorized Official - Middle Name:OLEG
Authorized Official - Last Name:AVANESOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-677-2505
Mailing Address - Street 1:193 ROUTE 9 SOUTH, SUITE 1D
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-3016
Mailing Address - Country:US
Mailing Address - Phone:732-677-2505
Mailing Address - Fax:732-677-2506
Practice Address - Street 1:193 ROUTE 9 STE 1D
Practice Address - Street 2:
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-3016
Practice Address - Country:US
Practice Address - Phone:732-677-2505
Practice Address - Fax:732-677-2506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-04
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 207R00000X
NJ25MA07613800207R00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ153630Medicare PIN