Provider Demographics
NPI:1710277421
Name:ROLAND A GHANEM,MD LLC
Entity Type:Organization
Organization Name:ROLAND A GHANEM,MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:A
Authorized Official - Last Name:GHANEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-790-6707
Mailing Address - Street 1:362 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:TOTOWA
Mailing Address - State:NJ
Mailing Address - Zip Code:07512-2554
Mailing Address - Country:US
Mailing Address - Phone:973-790-6707
Mailing Address - Fax:
Practice Address - Street 1:362 UNION BLVD
Practice Address - Street 2:
Practice Address - City:TOTOWA
Practice Address - State:NJ
Practice Address - Zip Code:07512-2554
Practice Address - Country:US
Practice Address - Phone:973-790-6707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02477700174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2746905Medicaid
NJ2746905Medicaid