| Prospect Medical Pc | |
|
277 Prospect Ave Hackensack NJ 07601-2570 | |
| (201) 968-1881 | |
| (201) 968-0330 |
| Full Name | Prospect Medical Pc |
|---|---|
| Speciality | Internal Medicine |
| Location | 277 Prospect Ave, Hackensack, New Jersey |
| Authorized Official Name and Position | Shan Sivendra (PRESIDENT) |
| Authorized Official Contact | 2019681881 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Prospect Medical Pc 277 Prospect Ave Unit Lg Hackensack NJ 07601-2512 Ph: (201) 968-1881 | Prospect Medical Pc 277 Prospect Ave Hackensack NJ 07601-2570 Ph: (201) 968-1881 |
| NPI Number | 1346365905 |
|---|---|
| Provider Enumeration Date | 03/20/2007 |
| Last Update Date | 08/01/2014 |
| Medicare PECOS PAC ID | 4486602737 |
|---|---|
| Medicare Enrollment ID | O20050104000551 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1346365905 | NPI | - | NPPES |
| 201403274 | Other | NJ | TAX ID |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | 25MA06930200 (New Jersey) | Primary |
| 332B00000X | Durable Medical Equipment & Medical Supplies | (* (Not Available)) | Secondary |
| Provider Name | Shan Sivendra |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1538154307 PECOS PAC ID: 7012974678 Enrollment ID: I20041215000322 |
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