Provider Demographics
NPI:1891151247
Name:EDISON MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:EDISON MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANARDHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLLU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-603-6003
Mailing Address - Street 1:1819 OAK TREE RD
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-2740
Mailing Address - Country:US
Mailing Address - Phone:732-603-6003
Mailing Address - Fax:732-662-7082
Practice Address - Street 1:1819 OAK TREE RD
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-2740
Practice Address - Country:US
Practice Address - Phone:732-603-6003
Practice Address - Fax:732-662-7082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-14
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05985700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty