Provider Demographics
NPI:1881844041
Name:MEDCOM HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:MEDCOM HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ILYAS
Authorized Official - Middle Name:
Authorized Official - Last Name:RAJPUT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-646-4064
Mailing Address - Street 1:258 N NEW RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08232-2170
Mailing Address - Country:US
Mailing Address - Phone:609-646-4064
Mailing Address - Fax:
Practice Address - Street 1:258 N NEW RD
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08232-2170
Practice Address - Country:US
Practice Address - Phone:609-646-4064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDCOM HEALTH SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6237002Medicaid
NJ896173Medicare PIN