Provider Demographics
NPI:1609144005
Name:ELITE PREMIER MEDICAL CARE LLC
Entity Type:Organization
Organization Name:ELITE PREMIER MEDICAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANEGAR
Authorized Official - Prefix:
Authorized Official - First Name:MIRYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:REVOREDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-595-7400
Mailing Address - Street 1:425 15TH AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07504-1811
Mailing Address - Country:US
Mailing Address - Phone:973-595-7400
Mailing Address - Fax:973-345-4156
Practice Address - Street 1:470 CHAMBERLAIN AVE STE 7
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07522-1000
Practice Address - Country:US
Practice Address - Phone:973-595-7400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07147400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8376808Medicaid
H21223Medicare UPIN