Provider Demographics
NPI:1245262385
Name:MEDCOM NEUROLOGICAL SERVICES, LLC
Entity type:Organization
Organization Name:MEDCOM NEUROLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ILYAS
Authorized Official - Middle Name:A
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:609-272-8526
Practice Address - Street 1:310 CHRIS GAUPP DR
Practice Address - Street 2:SUITE 101
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-4461
Practice Address - Country:US
Practice Address - Phone:609-909-5355
Practice Address - Fax:609-909-5357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0088072Medicaid
NJ097269Medicare ID - Type UnspecifiedGROUP