Provider Demographics
NPI:1457527053
Name:WHOLEHEALTHMD PA
Entity Type:Organization
Organization Name:WHOLEHEALTHMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGEI
Authorized Official - Middle Name:
Authorized Official - Last Name:KOCHLATYI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-974-7172
Mailing Address - Street 1:110 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CRESSKILL
Mailing Address - State:NJ
Mailing Address - Zip Code:07626-2002
Mailing Address - Country:US
Mailing Address - Phone:917-974-7172
Mailing Address - Fax:201-313-8888
Practice Address - Street 1:110 5TH ST
Practice Address - Street 2:
Practice Address - City:CRESSKILL
Practice Address - State:NJ
Practice Address - Zip Code:07626-2002
Practice Address - Country:US
Practice Address - Phone:917-974-7172
Practice Address - Fax:201-313-8888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08189600261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service