Provider Demographics
NPI:1265917926
Name:MENDHAM MEDICAL PRACTICE LLC
Entity type:Organization
Organization Name:MENDHAM MEDICAL PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:G
Authorized Official - Last Name:MARELLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-543-6505
Mailing Address - Street 1:19 E MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MENDHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07945-1503
Mailing Address - Country:US
Mailing Address - Phone:973-543-6505
Mailing Address - Fax:973-543-2967
Practice Address - Street 1:19 E MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:MENDHAM
Practice Address - State:NJ
Practice Address - Zip Code:07945-1503
Practice Address - Country:US
Practice Address - Phone:973-543-6505
Practice Address - Fax:973-543-2967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-28
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty