Provider Demographics
NPI:1952769960
Name:GERIATRICS AND INTERNAL MEDICINE ASSOCIATES OF NORTHEAST LLC
Entity Type:Organization
Organization Name:GERIATRICS AND INTERNAL MEDICINE ASSOCIATES OF NORTHEAST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSANTHI
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNADASA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MBBS
Authorized Official - Phone:347-308-4561
Mailing Address - Street 1:1 W RIDGEWOOD AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-2359
Mailing Address - Country:US
Mailing Address - Phone:347-308-4561
Mailing Address - Fax:
Practice Address - Street 1:1 W RIDGEWOOD AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-2359
Practice Address - Country:US
Practice Address - Phone:347-308-4561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty