Provider Demographics
NPI:1720368772
Name:ACTIVE AGING MEDICAL GROUP INC
Entity Type:Organization
Organization Name:ACTIVE AGING MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLESSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-425-3564
Mailing Address - Street 1:188 JEFFERSON ST
Mailing Address - Street 2:SUITE# 111
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-1622
Mailing Address - Country:US
Mailing Address - Phone:732-425-3564
Mailing Address - Fax:212-238-7760
Practice Address - Street 1:188 JEFFERSON ST
Practice Address - Street 2:SUITE# 111
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-1622
Practice Address - Country:US
Practice Address - Phone:732-425-3564
Practice Address - Fax:212-238-7760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty