Provider Demographics
NPI:1730363250
Name:OSTEOPATHIC MEDICAL CARE CENTER
Entity type:Organization
Organization Name:OSTEOPATHIC MEDICAL CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:
Authorized Official - First Name:ALEKSANDR
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIROSOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-475-5006
Mailing Address - Street 1:39-40 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-5419
Mailing Address - Country:US
Mailing Address - Phone:201-475-5006
Mailing Address - Fax:201-475-5009
Practice Address - Street 1:39-40 BROADWAY
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-5419
Practice Address - Country:US
Practice Address - Phone:201-475-5006
Practice Address - Fax:201-475-5009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06860100261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
G65075Medicare UPIN
074660Medicare PIN