Basic Information
| Provider Information | |||||||||
| NPI: | 1598012429 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSIOLOGIC ASSESSMENT SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1086 TEANECK RD | ||||||||
| Address2: | SUITE 4A | ||||||||
| City: | TEANECK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076664854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4843518459 | ||||||||
| FaxNumber: | 4843518810 | ||||||||
| Practice Location | |||||||||
| Address1: | 1086 TEANECK ROAD | ||||||||
| Address2: | SUITE 4A | ||||||||
| City: | TEANECK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076664854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018629900 | ||||||||
| FaxNumber: | 4843518810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2012 | ||||||||
| LastUpdateDate: | 06/02/2014 | ||||||||
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| AuthorizedOfficialLastName: | KLEAR | ||||||||
| AuthorizedOfficialFirstName: | JORDAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4843518459 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDSURANT HOLDINGS LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.