Provider Demographics
NPI:1619378239
Name:100 MAIN MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:100 MAIN MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LOWELL
Authorized Official - Middle Name:
Authorized Official - Last Name:TACLOB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-523-0317
Mailing Address - Street 1:100 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07505-1024
Mailing Address - Country:US
Mailing Address - Phone:973-523-0317
Mailing Address - Fax:973-684-8590
Practice Address - Street 1:100 MAIN ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07505-1024
Practice Address - Country:US
Practice Address - Phone:973-523-0317
Practice Address - Fax:973-684-8590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty