Provider Demographics
NPI:1659384360
Name:MEDWELL LLC
Entity Type:Organization
Organization Name:MEDWELL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANOUCHEHR
Authorized Official - Middle Name:T
Authorized Official - Last Name:SHAHAB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-819-1081
Mailing Address - Street 1:33 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07432
Mailing Address - Country:US
Mailing Address - Phone:201-689-0800
Mailing Address - Fax:201-689-0871
Practice Address - Street 1:33 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07432
Practice Address - Country:US
Practice Address - Phone:201-689-0800
Practice Address - Fax:201-689-0871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6126990001Medicare NSC
NJ045785Medicare PIN