Provider Demographics
NPI:1578973392
Name:BOSTON MEDICAL GROUP-NEW JERSEY, P.A.
Entity Type:Organization
Organization Name:BOSTON MEDICAL GROUP-NEW JERSEY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:L
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-808-2828
Mailing Address - Street 1:23275 S POINT DRIVE SUITE 100
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653
Mailing Address - Country:US
Mailing Address - Phone:443-542-9241
Mailing Address - Fax:443-542-9442
Practice Address - Street 1:1050 WALL STREET WEST, SUITE 120
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:NJ
Practice Address - Zip Code:07071
Practice Address - Country:US
Practice Address - Phone:949-200-6616
Practice Address - Fax:949-258-5076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty