Provider Demographics
NPI:1720361884
Name:INTEGRA MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:INTEGRA MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:LADAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAHRAMPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-447-7348
Mailing Address - Street 1:PO BOX 741
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07417-0741
Mailing Address - Country:US
Mailing Address - Phone:973-476-7527
Mailing Address - Fax:
Practice Address - Street 1:1124 E RIDGEWOOD AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3915
Practice Address - Country:US
Practice Address - Phone:201-447-7348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-26
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07654700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ229130Medicare PIN