Provider Demographics
NPI:1841427499
Name:BORIS MORDKOVICH MD PLASTIC SURGERY, PC
Entity Type:Organization
Organization Name:BORIS MORDKOVICH MD PLASTIC SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MORDKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-751-9490
Mailing Address - Street 1:96 LINWOOD PLZ # 307
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-3701
Mailing Address - Country:US
Mailing Address - Phone:201-751-9490
Mailing Address - Fax:908-730-0001
Practice Address - Street 1:96 LINWOOD PLZ # 307
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-3701
Practice Address - Country:US
Practice Address - Phone:201-751-9490
Practice Address - Fax:908-730-0001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-22
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA08107700174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ116745Medicare PIN