Provider Demographics
NPI:1972655256
Name:PROFESSIONAL OB GYN & INFERTILITY CENTER OF IRVINGTON P A
Entity Type:Organization
Organization Name:PROFESSIONAL OB GYN & INFERTILITY CENTER OF IRVINGTON P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SURESH
Authorized Official - Middle Name:RADHAKISHIN
Authorized Official - Last Name:THANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-399-9155
Mailing Address - Street 1:566 NYE AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-3241
Mailing Address - Country:US
Mailing Address - Phone:973-399-9155
Mailing Address - Fax:973-399-3936
Practice Address - Street 1:566 NYE AVE
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3241
Practice Address - Country:US
Practice Address - Phone:973-399-9155
Practice Address - Fax:973-399-3936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA37773207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1490702Medicaid
NJ1490702Medicaid
NJC33524Medicare UPIN