Provider Demographics
NPI:1295997609
Name:CORNEL MIRCEA MD PA
Entity type:Organization
Organization Name:CORNEL MIRCEA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORNEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRCEA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-680-5522
Mailing Address - Street 1:123 HIGHLAND AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:GLEN RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07028-1522
Mailing Address - Country:US
Mailing Address - Phone:973-680-5522
Mailing Address - Fax:973-680-1180
Practice Address - Street 1:123 HIGHLAND AVE
Practice Address - Street 2:STE 104
Practice Address - City:GLEN RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07028-1527
Practice Address - Country:US
Practice Address - Phone:973-680-5522
Practice Address - Fax:973-680-1180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA065118174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJB37481Medicare UPIN