Basic Information
| Provider Information | |||||||||
| NPI: | 1245505601 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RACKOVSKY | ||||||||
| FirstName: | ORI | ||||||||
| MiddleName: | AVRAHAM | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1130 MCBRIDE AVENUE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | WOODLAND PARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738121400 | ||||||||
| FaxNumber: | 9738121404 | ||||||||
| Practice Location | |||||||||
| Address1: | 468 PARISH DR STE 6 | ||||||||
| Address2: | |||||||||
| City: | WAYNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074704671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739882100 | ||||||||
| FaxNumber: | 9739526248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2012 | ||||||||
| LastUpdateDate: | 04/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 25MA10376500 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 0633488 | 05 | NJ | MEDICAID |