Provider Demographics
NPI:1639479009
Name:PATIENT CENTERED MEDICAL ASSOCIATES, PA
Entity Type:Organization
Organization Name:PATIENT CENTERED MEDICAL ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-746-3400
Mailing Address - Street 1:54 PLYMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2137
Mailing Address - Country:US
Mailing Address - Phone:973-746-3400
Mailing Address - Fax:973-746-6214
Practice Address - Street 1:54 PLYMOUTH ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2137
Practice Address - Country:US
Practice Address - Phone:973-746-3400
Practice Address - Fax:973-746-6214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJDO6476Medicare UPIN