Provider Demographics
NPI:1952739476
Name:TRISTATE WELLNESS & MEDICAL CARE PA
Entity Type:Organization
Organization Name:TRISTATE WELLNESS & MEDICAL CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:YASIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-875-7121
Mailing Address - Street 1:199 ROUTE 284
Mailing Address - Street 2:
Mailing Address - City:WANTAGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07461-3417
Mailing Address - Country:US
Mailing Address - Phone:973-875-7121
Mailing Address - Fax:973-875-7123
Practice Address - Street 1:199 ROUTE 284
Practice Address - Street 2:
Practice Address - City:WANTAGE
Practice Address - State:NJ
Practice Address - Zip Code:07461-3417
Practice Address - Country:US
Practice Address - Phone:973-875-7121
Practice Address - Fax:973-875-7123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-18
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05330800207R00000X, 207RI0200X
NY197792-1207R00000X, 207RI0200X
MI4301087529207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01496762Medicaid
NJ342010801Medicaid
NJ1054395Medicaid
NJE29949Medicare UPIN