Provider Demographics
NPI:1295516409
Name:EVERGREEN MEDICAL GROUP PC
Entity type:Organization
Organization Name:EVERGREEN MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRIGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHTENDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-791-7771
Mailing Address - Street 1:887 KINDERKAMACK RD STE 2
Mailing Address - Street 2:
Mailing Address - City:RIVER EDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07661-2307
Mailing Address - Country:US
Mailing Address - Phone:201-464-0860
Mailing Address - Fax:
Practice Address - Street 1:887 KINDERKAMACK RD STE 2
Practice Address - Street 2:
Practice Address - City:RIVER EDGE
Practice Address - State:NJ
Practice Address - Zip Code:07661-2307
Practice Address - Country:US
Practice Address - Phone:201-464-0860
Practice Address - Fax:888-440-2752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-12
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty