Provider Demographics
NPI:1861671737
Name:SOUTH MOUNTAIN MEDICAL ASSOCIATES,P.C.
Entity Type:Organization
Organization Name:SOUTH MOUNTAIN MEDICAL ASSOCIATES,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-736-8119
Mailing Address - Street 1:1500 PLEASANT VALLEY WAY
Mailing Address - Street 2:SUITE 302
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2956
Mailing Address - Country:US
Mailing Address - Phone:973-736-8119
Mailing Address - Fax:
Practice Address - Street 1:1500 PLEASANT VALLEY WAY
Practice Address - Street 2:SUITE 302
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2956
Practice Address - Country:US
Practice Address - Phone:973-736-8119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA44815207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE56154Medicare UPIN
NJ052570Medicare PIN