Provider Demographics
NPI:1851825947
Name:GARDEN STATE SPECIALTY CARE, LLC
Entity type:Organization
Organization Name:GARDEN STATE SPECIALTY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AYEZA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHSIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:097-962-1196
Mailing Address - Street 1:1418 NEW RD STE 2
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08225-1179
Mailing Address - Country:US
Mailing Address - Phone:609-642-2663
Mailing Address - Fax:609-642-2663
Practice Address - Street 1:1418 NEW RD STE 2
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08225-1179
Practice Address - Country:US
Practice Address - Phone:609-796-2119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-14
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 208D00000X, 207R00000X
NJ25MB05436700207RI0200X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0591661Medicaid