Provider Demographics
NPI:1700245255
Name:MOUNT PROSPECT MEDICAL GROUP,LLC
Entity Type:Organization
Organization Name:MOUNT PROSPECT MEDICAL GROUP,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:G
Authorized Official - Last Name:SALERNO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-672-2455
Mailing Address - Street 1:613 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07017-1905
Mailing Address - Country:US
Mailing Address - Phone:973-672-2455
Mailing Address - Fax:973-675-0040
Practice Address - Street 1:570 PARK AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07017-1904
Practice Address - Country:US
Practice Address - Phone:973-672-8573
Practice Address - Fax:973-675-0040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-12
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07308500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty