Provider Demographics
NPI:1811229875
Name:LONGEVITY MEDICAL GROUP, P.A.
Entity Type:Organization
Organization Name:LONGEVITY MEDICAL GROUP, P.A.
Other - Org Name:LONGEVITY MEDICAL GROUP, P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:COLETTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-265-4647
Mailing Address - Street 1:PO BOX 8069
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07653-8069
Mailing Address - Country:US
Mailing Address - Phone:201-265-4647
Mailing Address - Fax:
Practice Address - Street 1:2 SEARS DR
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3539
Practice Address - Country:US
Practice Address - Phone:201-265-4647
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA42243174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty