Provider Demographics
NPI:1730135682
Name:WEST PATERSON SPECIALTY CLINIC INC
Entity Type:Organization
Organization Name:WEST PATERSON SPECIALTY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:S
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-569-4488
Mailing Address - Street 1:871 MCBRIDE AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-2748
Mailing Address - Country:US
Mailing Address - Phone:973-569-4488
Mailing Address - Fax:973-569-4743
Practice Address - Street 1:871 MCBRIDE AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07424-2748
Practice Address - Country:US
Practice Address - Phone:973-569-4488
Practice Address - Fax:973-569-4743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA61942207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8549401Medicaid
NJ8472505Medicaid
NJG26105Medicare UPIN
NJ8472505Medicaid
NJ047740Medicare ID - Type UnspecifiedAIROOD
NJG25074Medicare UPIN