Provider Demographics
NPI:1861719718
Name:GARDEN STATE GERIATRICS LLC
Entity type:Organization
Organization Name:GARDEN STATE GERIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KAVITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUBRAMANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-491-1093
Mailing Address - Street 1:53 HEATHER HILL RD
Mailing Address - Street 2:
Mailing Address - City:CRESSKILL
Mailing Address - State:NJ
Mailing Address - Zip Code:07626
Mailing Address - Country:US
Mailing Address - Phone:732-491-1093
Mailing Address - Fax:201-530-5391
Practice Address - Street 1:773 TEANECK ROAD
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666
Practice Address - Country:US
Practice Address - Phone:201-530-5390
Practice Address - Fax:201-530-5391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-30
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07857500261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0153982Medicaid
NJ0153982Medicaid