Provider Demographics
NPI:1760490148
Name:ADVANCED NEUROLOGY CENTER LLC
Entity Type:Organization
Organization Name:ADVANCED NEUROLOGY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SRINIVASA
Authorized Official - Middle Name:
Authorized Official - Last Name:POTLURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-218-1180
Mailing Address - Street 1:PO BOX 1075
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08876-1075
Mailing Address - Country:US
Mailing Address - Phone:908-218-1180
Mailing Address - Fax:908-218-1718
Practice Address - Street 1:676 ROUTES 202 206 N
Practice Address - Street 2:BLDG 2, SUITE 1NE
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807
Practice Address - Country:US
Practice Address - Phone:908-218-1180
Practice Address - Fax:908-218-1718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA071375002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2229034000OtherKEYSTONE
1545098OtherAMERIHEALTH
2K4368OtherHEALTHNET
P2486490OtherOXFORD
NJ8686301Medicaid
60008696OtherHORIZON NJ HEALTH
P2486490OtherOXFORD