Basic Information
| Provider Information | |||||||||
| NPI: | 1447878277 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED NEUROMED LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 445 FACTORY ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136012729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157824207 | ||||||||
| FaxNumber: | 3157828699 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 DEGRAW AVE | ||||||||
| Address2: | |||||||||
| City: | TEANECK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076664000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178235231 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2020 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | CHARLOTTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTAILING | ||||||||
| AuthorizedOfficialTelephone: | 3157824207 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.