Provider Demographics
NPI:1700961034
Name:MEDICAL INTERNISTS ASSOC. PA
Entity Type:Organization
Organization Name:MEDICAL INTERNISTS ASSOC. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-797-4503
Mailing Address - Street 1:17-15 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-1552
Mailing Address - Country:US
Mailing Address - Phone:201-797-4503
Mailing Address - Fax:201-797-4270
Practice Address - Street 1:17-15 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-1552
Practice Address - Country:US
Practice Address - Phone:201-797-4503
Practice Address - Fax:201-797-4270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2843102Medicaid
NJ=========OtherTAX ID
NJ526645Medicare ID - Type Unspecified