Provider Demographics
NPI:1598275141
Name:FJPL EAST ORANGE PC
Entity Type:Organization
Organization Name:FJPL EAST ORANGE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MAGDY
Authorized Official - Middle Name:F
Authorized Official - Last Name:MAHMOUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-370-4000
Mailing Address - Street 1:110 SQUIRE HILL RD
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-2516
Mailing Address - Country:US
Mailing Address - Phone:973-370-4000
Mailing Address - Fax:
Practice Address - Street 1:276 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07017-2889
Practice Address - Country:US
Practice Address - Phone:973-370-4000
Practice Address - Fax:862-904-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08818300207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0263273Medicaid