Provider Demographics
NPI:1245695766
Name:ED MEDICAL ASSOCIATES, INC
Entity type:Organization
Organization Name:ED MEDICAL ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELI
Authorized Official - Middle Name:
Authorized Official - Last Name:DJEBIYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-569-9010
Mailing Address - Street 1:140 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-6581
Mailing Address - Country:US
Mailing Address - Phone:201-569-9010
Mailing Address - Fax:201-541-7942
Practice Address - Street 1:140 GRAND AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-6581
Practice Address - Country:US
Practice Address - Phone:201-569-9010
Practice Address - Fax:201-541-7942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA068121207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherTIN