Provider Demographics
NPI:1629135272
Name:GARDEN STATE PRIMARY CARE, PA
Entity Type:Organization
Organization Name:GARDEN STATE PRIMARY CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MUDASSAR
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARIF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-868-1494
Mailing Address - Street 1:711 KEARNY AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNY
Mailing Address - State:NJ
Mailing Address - Zip Code:07032-3003
Mailing Address - Country:US
Mailing Address - Phone:973-868-1494
Mailing Address - Fax:
Practice Address - Street 1:711 KEARNY AVE
Practice Address - Street 2:
Practice Address - City:KEARNY
Practice Address - State:NJ
Practice Address - Zip Code:07032-3003
Practice Address - Country:US
Practice Address - Phone:973-868-1494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ097878Medicare ID - Type Unspecified