Provider Demographics
NPI:1710525662
Name:SIVAM DIABETES & PRIMARY CARE LLC
Entity Type:Organization
Organization Name:SIVAM DIABETES & PRIMARY CARE LLC
Other - Org Name:SIVAM DIABETES, NUTRITION AND FAMILY HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MAVIS
Authorized Official - Middle Name:CAMALITA
Authorized Official - Last Name:ERMAKOV
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APN, FHNP-BC, R
Authorized Official - Phone:201-618-1472
Mailing Address - Street 1:78 KENMORE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07106-1026
Mailing Address - Country:US
Mailing Address - Phone:201-618-1472
Mailing Address - Fax:
Practice Address - Street 1:1120-1122 SOUTH ORANGE AVENUE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07106
Practice Address - Country:US
Practice Address - Phone:201-618-1472
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-11
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0143533620Medicaid