Provider Demographics
NPI:1639408461
Name:AVICENNA MEDICAL ARTS, PLLC
Entity Type:Organization
Organization Name:AVICENNA MEDICAL ARTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:VEDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-522-3664
Mailing Address - Street 1:PO BOX 302
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-0302
Mailing Address - Country:US
Mailing Address - Phone:646-522-3664
Mailing Address - Fax:646-522-3664
Practice Address - Street 1:660 TENNENT RD
Practice Address - Street 2:SUITE 104
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-3163
Practice Address - Country:US
Practice Address - Phone:646-522-3664
Practice Address - Fax:732-831-6171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08792700202C00000X, 207L00000X, 208VP0014X, 207L00000X
NY207274208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical ExaminerGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100022929Medicare PIN