Basic Information
| Provider Information | |||||||||
| NPI: | 1316020035 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EFREMOVA | ||||||||
| FirstName: | IRINA | ||||||||
| MiddleName: | V. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 317 GEORGE ST | ||||||||
| Address2: | 3RD FLOOR, PROVIDER ENROLLMENT | ||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089012008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322356772 | ||||||||
| FaxNumber: | 7322358347 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 HOES LN | ||||||||
| Address2: | UNIVERSITY BEHAVIORAL HEALTHCARE CENTER | ||||||||
| City: | PISCATAWAY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088545627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322354402 | ||||||||
| FaxNumber: | 7322353923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0805X | 25MA068611 | NJ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 8051402 | 05 | NJ | MEDICAID |