Provider Demographics
NPI:1609960418
Name:EASTERN VASCULAR LLC
Entity Type:Organization
Organization Name:EASTERN VASCULAR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MINTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-625-0112
Mailing Address - Street 1:16 POCONO RD
Mailing Address - Street 2:SUITE 313
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2901
Mailing Address - Country:US
Mailing Address - Phone:973-625-0112
Mailing Address - Fax:973-625-0721
Practice Address - Street 1:16 POCONO RD
Practice Address - Street 2:SUITE 313
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2901
Practice Address - Country:US
Practice Address - Phone:973-625-0112
Practice Address - Fax:973-625-0721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ034838Medicare PIN