Provider Demographics
NPI:1730200841
Name:SEBASTIAN MEDICAL ASSOCIATES CORPORATION
Entity type:Organization
Organization Name:SEBASTIAN MEDICAL ASSOCIATES CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNAMARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-458-0422
Mailing Address - Street 1:PO BOX 1719
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07015-1719
Mailing Address - Country:US
Mailing Address - Phone:973-458-0422
Mailing Address - Fax:973-458-0661
Practice Address - Street 1:476 COLFAX AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-1624
Practice Address - Country:US
Practice Address - Phone:973-594-7977
Practice Address - Fax:973-594-9983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08164800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherTAX IDENTIFICATION NUMBER