Provider Demographics
NPI:1831789338
Name:ICONIC MEDICAL AND WELLNESS CENTERS
Entity type:Organization
Organization Name:ICONIC MEDICAL AND WELLNESS CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOROGODSKY
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:908-403-1160
Mailing Address - Street 1:5 COLD HILL RD S STE 26J
Mailing Address - Street 2:
Mailing Address - City:MENDHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07945-3208
Mailing Address - Country:US
Mailing Address - Phone:973-531-6377
Mailing Address - Fax:
Practice Address - Street 1:5 COLD HILL RD S STE 26J
Practice Address - Street 2:
Practice Address - City:MENDHAM
Practice Address - State:NJ
Practice Address - Zip Code:07945-3208
Practice Address - Country:US
Practice Address - Phone:973-531-6377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service